Health and Information Form

Forest Pulse

C/O Heart of the Forest Community Special School,
Speech House, Coleford, Glos, GL16 7EJ

Tel/Fax: 01594 826357`

 

“GETTING TO KNOW YOU” HEALTH & INFORMATION FORM To be completed for ALL children attending Forest Pulse activities

Please complete this form in as much detail as possible to help us know your child and to ensure that he/she gets maximum benefit from any Forest Pulse Activities he/she is involved with. It is often the little things which are important to put children at their ease and help them feel secure in a new situation! If there is any behaviour or activity you are trying to encourage or discourage we will try and follow this through if we can – if we know about it! Please ensure that all sections of the form are completed, it may be returned if insufficient information is provided.

 

My full name is ................................................................................................................... My friends call me .................................................................

 

I am .......................................... Years old, and I was born on .........................................................................................................................................

 

My home address is .........................................................................................................................................................................................................

 

My parents names are .....................................................................................................................................................................................................

 

My home phone no is ................................................................................... Email address ..........................................................................................

 

My parents/guardians mobiles are .................................................................................................................................................................................

 

I live with (please tell us everyone who lives at home) ...................................................................................................................................................

.......................................................................................................................................................................................................................................

 

I go to school at ......................................................................................... Do you have a Statement of Educational Needs? .....................................

 

Professionals I see regularly .........................................................................................................................................................................................

 

Please provide details of all your special needs/disabilities, including any diagnoses, and explain how this affects you (please continue on a separate sheet if necessary)

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I take the following medication .....................................................................................................................................................................................

Please tick if any prescribed medication should be given whilst your child is at Forest Pulse activities box and complete separate Medicine Record.  Note: non-prescription medicines (e.g. cough mixture, Calpol etc) can only be given with the written consent of parents.

My doctors name, address and telephone number is .................................................................................................................................................

....................................................................................................................................................................................................................................

 

I am allergic to ............................................................................................................................................................................................................

Date last tetnus .................................................................... Immunisations received ...............................................................................................

 

I use the following communication methods ...............................................................................................................................................................

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Toileting help needed;    If pads used - changed lying  box 1      changed standing box 3 

To be encouraged to use toilet when pad changed  box 2

Any other relevant personal care information ............................................................................................................................................................

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Help I need to get dressed/undressed .......................................................................................................................................................................

Help I need eating drinking ........................................................................................................................................................................................

Help I need to get around ......................................................................................................................................…................................................

Things which frighten me .....................................................................................................................................….................................................

Things which make me angry................................................................................................................................…................................................

How I react when I’m frightened/angry................................................................................................................…...................................................

What calms me...………...................................................................................................................................…....................................................

Am I likely to wonder/run off…..........What might trigger this….................................................................................................................................

Any other behaviours we should be aware of ……………………….........................................................................................................................

Things I really like doing ......................................................................................................................................…..............................................

Special things I should be doing ............................................................................................................................……........................................

Things I shouldn’t be doing! .................................................................................................................................….............................................

Additional information ...........................................................................................................................................……........................................

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IF YOU CANNOT CONTACT MY PARENTS AT HOME IN AN EMERGENCY, PLEASE CONTACT ONE OF THE PEOPLE, THEIR NAME, RELATIONSHIP, ADDRESS AND TELEPHONE NUMBER I GIVE BELOW:

1) ..........................................................................................................................................................................……..

..............................................................................................................................................................................……...

2) ..........................................................................................................................................................................……...

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NAME OF PARENT/GUARDIAN (please print) ..................................................................................................…...

 

SIGNATURE ......................................................................... DATE ...................................................................…….