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Please ask your doctor to complete this page.

Name of student…………………………………………………… Date of Birth…………………….

Height …………………………………  Weight……………….………………….

Does this student have any particular medical problems?  …………..  Yes  /  No

Does he/she require any regular medication?  ………………………..  Yes  /  No

Does he/she suffer from asthma?  ……………………………………...  Yes  /  No

Has he/she ever suffered from bulimia/anorexia?  ….………………..  Yes  /  No

Does he/she have any allergies (animals, pain-killers, foods, etc.)?    Yes  /  No

Does he/she have any food intolerances?  ……………………………  Yes  /  No

Is there any family history of mental health problems?  ……………..  Yes  /  No

Is this student able to take part in sports?  ……………………………   No  / Yes

Please give full details of any health concerns.

…………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Vaccinations received:

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Against…………………………………………………….Date …………………

Doctor's Signature…………………………………………………Clinic/Practice stamp

YOUR PASSPORT

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