Junior Health Questionnaire


In the interest of your child’s safety please complete the following health questionnaire in confidence.



Name		:
Address		:
Tel Number	(H)                                        
		(A/H)                                         
		(M)
Next of Kin	:
Name		:
Address		:
Tel Number	(H)                                         
		(A/H)                                         
		(M)




Does your child have any allergies e.g. bandaids, massage oil, antibiotics and other drugs?





Is your child currently taking any long-term medication such as Ventolin, Insulin, cortisone?





Does your child suffer from any long-term conditions such as epilepsy, diabetes, asthma, heart murmur?





Has your child had any major surgery?





Is there any family history of serious disease? 





Is there any other issue you would like your coach to be aware of regarding your child’s health?





PLEASE RETURN THIS FORM TO ME ASAP.