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Child Medical History Form Full name: Date of birth: / / Sex: Male Female Address: Postcode: Mobile Tel no: no: Parent/Guardian Work no: mob no: Parent/Guardian email: Are you happy for us to contact you by: Text Phone Email (please tick all that apply) Doctor’s details: Tel no: Doctor’s name: Address: Postcode: Is your child currently: Doctor’s details: Yes / No Give details (continue overleaf if necessary) Receiving treatment from Doctor’s name: the doctor Address: Tel no: Taking medication Postcode: Has your details: child ever suffered from: Doctor’s Yes / No Give details (continue overleaf if necessary) Tel no: Allergies to medicines Doctor’s name: Address: Any serious illness Postcode: Congenital heart condition Any other congenital condition Parent/Guardian signature Date Medical history update Please check that the health information on this form is still correct..
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