Medical Questionnaire

Please write down below if your child has had any of the following and provide a brief description:

Asthma

Allergies to food

Allergies to Medicine

Allergies (other - insect bites etc

Colds

Convulsions

Depression

Diabetes

Dizziness

Ears/Hearing

Epilepsy

Eyes

Heart

Mental Illness

Nerves

Nose

(including frequent nose bleeds)

Sleep Difficulties

Speech

Surgical Operations

Throat

Any medication requirements

(prescribed or otherwise)