FORMSSV3(a)

FROME COMMUNITY COLLEGE                          
ANNUAL MEDICAL INFORMATION 

Students under 18 
(at start of the Academic Year)

Date:  All DofE Expeditions and Trips for 2021-2022

Parts A and B to be completed and returned to the party leader as soon as possible

PART A – CONFIDENTIAL MEDICAL QUESTIONNAIRE

Student’s Name:		
Parent/Guardian/Next of kin name & initials:		
Home Address:	

Contact Tel No in case of emergencies:	Home:	
	
	Mobile:	
	
Name and Address of family Doctor:	
	
Tel No of family Doctor:	
	
Student’s NHS No:		Date of Birth:

1.	Has your son/daughter had any of the following:-

	Yes	No	
Asthma or bronchitis			
Sight or hearing impairments			
Heart condition			
Fits, fainting or blackouts			
Severe headaches			
Diabetes			
Allergies to any known drugs			
Any other allergies, eg material, food, medicine, pollen, dust			
Other illness or disability			
Recent bed wetting			
Sleep-walking			
Travel sickness			
Anaphylaxis			

2. If the answer to any of the questions is YES, please give details in the space below:

3. Has your son/daughter received vaccination against Tetanus in the last ten years?
	YES	NO
	
4. Has your son/daughter received medical or surgical treatment of 
any kind from either your family doctor or hospital during the past three months?	YES	NO
	
5. Has your son/daughter been given specific medical advice to follow in emergencies?	YES	NO
	
If the answer to either of questions 4 and 5 is YES please give the details here:- (including dosage of any medicines/tablets).	

	Medication; Dosage and frequency; 

6. Details of any special diet.	

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  
 
PART B – CERTIFICATION

I consent to my son/daughter receiving any necessary medical treatment for any injury or illness during 
DofE expeditions and trips in 2020-2021.

Signed:

	Date	

(Father/Mother/Legal Guardian)

NOTE:

If you would rather discuss any medical matter privately with the party leader please make an appointment to do so.