Student Medical Questionnaire


To help us support your daughter/son with their health whilst at college please answer the questions below. This information will be kept private and only shared with medical professionals or select members of staff in the interests of your daughter/sons’ health and well-being.

If your daughter/son wishes to speak to someone about any personal issues please let us know in advance or on arrival that they would like to talk to the Vice Principal, who is the Head of Student Welfare.

Family name:

Given name:

Blood type:

Please complete these medical questions

Please mark YES as [ / ] and NO as [ x ].


[ ] Does your daughter/son have any medical conditions?

If yes, please specify.

[ ] Does your daughter/son take Doctor prescribed medication for anything?

[ ] Has your daughter/son had any serious illnesses? How old were they?

[ ] Has your daughter/son had a serious accident? Did they go to hospital, if yes how long for?

[ ] Does your daughter/son have allergies to anything? (nuts, insect stings, food, medicine)

If yes, what symptoms do they have?

[ ] Does your daughter/son have any dietary requirements?

[ ] Does your daughter/son have asthma?

If yes, do they have an inhaler?

[ ] Does your daughter/son have epilepsy or seizures?

[ ] Are they being treated by a Doctor?
[ ] Do they have prescribed medication to take?

[ ] Has your daughter/son had Malaria?

If yes, when?

[ ] Does your daughter/son have any injuries or illnesses that prevent them from playing sport?

If yes, please give details.

[ ] Does your daughter/son have dizziness or fainting spells?

[ ] Can your daughter/son swim?

[ ] Has your daughter/son had an eye test recently? If yes, when?

[ ] Has your daughter/son visited a Dentist recently? If yes, when?

[ ] Has your daughter/son had support from anyone other than family or teachers for their well-being?

If yes, please give details.

If there is any other information you would like to share with the Head of Student Welfare about the health and well-being of your daughter/son then please write it here:

Please sign to confirm that the information you have provided is correct and that you agree to Cambridge Leadership College staff acting on your behalf regarding all health matters for your daughter/son.

Parent Signature:

Parent Name [in block capitals]:

Date Completed: