Health Appraisals and Medical Examinations for children in Special Schools and Learning Support Centres Reference Number:

Transcription

1 This is an official Northern Trust policy and should not be edited in any way Health Appraisals and Medical Examinations for children in Special Schools and Learning Support Centres Reference Number: NHSCT/11/383 Target audience: This policy is directed to school nursing staff and community paediatric medical staff (associate specialists, staff grade, specialty doctors and trainee paediatricians) Sources of advice in relation to this document: Dr. Clare Bailey, Associate Specialist Mrs. Loraine Calvert, School Nurse Manager Replaces (if appropriate): Previous NHSCT Health Appraisals and Medical Examinations for children in Special Schools and Learning Support Centres (NHSCT/09/229) Type of Document: Directorate Specific Approved by: Policy, Standards and Guidelines Committee Date Approved: 12 August 2010 Date Issued by Policy Unit: 3 March 2011 NHSCT Mission Statement To provide for all, the quality of service we expect for our families, and ourselves.

2 Protocol for Health Appraisals and Medical Examinations for children in Special Schools and Learning Support Centres August 2010

3 Contents Introduction to Policy 2 Purpose of Policy 2 Target Audience 2 Equality, Human Rights and Disability Discrimination Act (DDA) 2 Alternative Formats 2 Sources of advice in relation to this document 2 Consultants Northern 3 Western 4 Southern 5 Belfast 6 South Eastern 7 Protocol for Health Appraisals and Medical Examinations in 8 Special S Schools and Beechgrove Beechgrove Questionnaire 10 Special S Schools Questionnaire 12 Invitation to Medical 14 Protocol for Health Appraisals and Medical Examinations in 15 Special M Schools and Learning Support Centres Questionnaire Children with Statements 17 Protocol for Health Appraisals and medical Examinations in Jordanstown Special Schools 19 Questionnaire for Pupils with Visual Impairment 21 Questionnaire for Pupils with hearing Impairment 23 Protocol for Health Appraisals and Medical Examinations in Thornfield House School and the Speech & Language Unit, Model Primary School, Ballymoney 25 Questionnaire Speech and Language Impairment 27 Health Appraisal Outcome letter to parent 29 1

4 Introduction to Policy This document was first written in 2009 in order to harmonise school nursing and medical practices within special schools across legacy trusts. It is intended that this document should be used in conjunction with Health Appraisals: Guidance for School Nurses and Paediatricians (approved 2009). Purpose of Policy This protocol outlines procedures and practices within the Northern Health and Social Care Trust (NHSCT) for registered nursing staff and community paediatricians who undertake health appraisals and medical examinations for children within special schools and learning support centres. Target Audience This policy is directed to school nursing staff and community paediatric medical staff (associate specialists, staff grade, specialty doctors and trainee paediatricians). Equality, Human Rights and DDA The policy is purely clinical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Responsibilities The Director has overall responsibilities for the implementation of this policy within the Directorate. The Assistant Director has responsibility to ensure managers and their staff are aware of and adhere to this policy. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 2

5 Consultant Paediatricians/Associate Specialists Northern Ireland Northern Trust Dr Alison Livingstone Consultant Paediatrician Tel: CDC Ferrard Site Fax: Antrim Dr Kim Troughton Tel: Consultant Paediatirican CDC Fax: Ferrard Site ANTRIM Dr M Clare Bailey Tel: Associate Specialist Ferguson House Fax: Manse Road Newtownabbey clare.bailey@northerntrust.hscni.net Dr Pauline Kennedy Associate Specialist Tel: Health Office Slemish CSC Fax: Cushendall Road Ballymena pauline.kennedy@northerntrust.hscni.net Dr Yvonne Doherty Associate Specialist Tel: ext 201 Health Office 44 King Street Fax: Magherafelt yvonne.doherty@northerntrust.hscni.net Dr Deirdre Walsh Tel: Consultant Paediatrician 4 Newbridge Road Fax: Coleraine deirdre.walsh@northerntrust.hscni.net Dr J Nicholson Tel: Consultant Paediatrician Antrim Hospital Fax: Antrim john.nicholson@northerntrust.hscni.net 3

6 Western Health & Social Care Trust Dr Sandi Hutton Consultant Paediatrican Tel: Bridgeview House Gransha Park Fax: Clooney Road Londonderry Dr Vivien Dale Associate Specialist Tel: Waterside Health & Social Care Centre Spencer Road Londonderry BT47 6AQ Fax: Dr Erin Knowles Associate Specialist Tel: Great James Street Health Centre Great James Street Londonderry Fax: Dr Kusum Sharma Consultant Paediatrician Tel: Mountjoy Road Health Centre Fax: Omagh 4

7 Southern Health & Social Care Trust Dr James Hughes Consultant Paediatrician Tel: John Mitchell Place Newry Fax: Dr Paula McAlinden Consultant Paediatrician Tel:

8 Belfast Health & Social Care Trust Dr Anne Armstrong Consultant Paediatrician Tel: The Arches Centre Westminster Avenue North Fax: Belfast BT4 1NS Dr Moira Stewart Consultant Paediatrician Tel: Carlisle Centre 40 Antrim Road Fax: Belfast BT15 2AX Dr Alan McMillan Associate Specialist Tel: Carlisle Centre 40 Antrim Road Fax: Belfast BT15 2AX Dr Daphne Primrose Consultant Paediatrician Tel: The Arches Centre Westminster Avenue North Fax: Belfast BT4 1NS 6

9 South Eastern Trust Dr Cathy McPherson Consultant Paediatrician Tel: Newtownards Fax: 028 Dr Jayne Larkin Consultant Paediatrician Tel: 028 Fax: 028 Newtownards 7

10 Protocol for Health Appraisals and Medical Examinations in Special S Schools and Beechgrove 1 Special S Schools Sandleford Coleraine Kilronan Magherafelt Loughan - Castle Tower Campus, Ballymena Riverside Antrim Roddensvale Larne Hillcroft Newtownabbey Beechgrove is a school for children of primary school age who have a physical disability and is a campus within Castle Tower. General Comments 1. All health appraisals and medical examinations will be undertaken jointly with school nurse and community paediatrician 2. The CHS 24R should not be issued to pupils at these schools. Clerical staff should issue relevant questionnaire either Special S School questionnaire or Beechgrove questionnaire together with Invitation to Medical 3. Provided consent is obtained, health appraisal and examination will take place, even in the absence of a parent (Homefirst legacy only) a. Children may travel some distance to attend their specialist education provision and therefore parents may have difficulty attending appointments in school b. Paediatricians will exert their own professional judgement as to whether or not a local clinic appointment will also be necessary 4. Where an appointment has been cancelled, this will be rescheduled as soon as possible 5. In the event of a pupil being absent or consent not having been obtained, one further appointment will be offered the following school year only. In the event of a joint examination still not taking place despite two invitations consideration must be given to the most appropriate action necessary. 6. In the event of a carer not being present for the appointment, information will be shared using the standard letter Health Appraisal Outcome Special Schools and LSC 1 Beechgrove now forms part of the Castle Tower Campus and it is not clear how easy it will be, in the future, to ascertain which pupil is assigned to which campus 8

11 7. CHS 18R is completed jointly by school nurse and paediatrician and returned to clerical staff for entry onto CHS. Clerical staff will record height, weight, vision and hearing as school nurse activity and any other information will be recorded against the paediatrician. 8. Paediatrician will make a handwritten record of the consultation 9. The paediatrician will forward information to the GP decision to be reached options include: a. Copy CHS18R b. Standard letter issued or c. Copy of file note (handwritten) New Entrants 1. All new entrants regardless of age will be offered a health appraisal and medical examination Reviews 1. It is the responsibility of the community paediatrician to identify those children that require to be reviewed in any one school year a. A child who is currently attending a consultant community paediatrician within the Trust should have the CHS 18R completed as examination not required but the child should be recalled for 12 months to ascertain whether or not the child continues to be followed up by a consultant 2. Review appointments will be offered on those pupils not currently attending a consultant community paediatrician within Northern HSC Trust a. Timing of subsequent reviews will be determined at medical appointment by the paediatrician and will be offered no less frequently than every 2 years. This will be recorded on CHS18R. b. All young people in their final full year at school (age 18 at special S schools) should have a final medical examination. The paediatrician will share the outcome with the General Practitioner this should include reference to condition specific guidelines where available. 9

12 Name Address Date of Birth School GP 1. Is your child in good health at present?.. If "no" please give details: Is your child on regular medication/treatment?... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 3. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 4. Do you suspect poor hearing?. If yes please give details: 5. Do you suspect poor vision? If yes please give details: continued overleaf 10

13 6. Does your child have epilepsy?. If "yes", please give brief description of seizures (including how often) 7. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam? If yes has it been prescribed for emergency use in school? 8. Does your child have a bedwetting problem?. Is this a new problem? Is your child dry by day?. 9. Does your child have any bowel problems? If yes please give details Does your child have behaviour problems?... If "yes" please give details: Does your child have any known allergies?. If yes please give details and state if any emergency medication is required? Do you have any particular worries about your child? If "yes" please give details: Do you intend to be at the medical appointment?. If no do you still want your child to be seen and examined?... Yes No If you are unable to attend and you want your child to be seen can s/he be accompanied by teacher/classroom assistant, if necessary?..... Are you happy for the doctor/nurse to talk to the teacher about your child, if necessary? Do you consent to the doctor providing a relevant report to the Education & Library Board for the annual review of statement, if necessary?. Please state your current address if different from overleaf: Please state your contact telephone number(s).... Signature of Person with Parental Responsibility Date. 11

14 School Health Service Special S Schools Questionnaire Name Address Date of Birth School GP 1. Is your child in good health at present?.. If "no" please give details: Is your child on regular medication/treatment?... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 3. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 4. Do you suspect poor hearing?. If yes please give details: 5. Do you suspect poor vision? If yes please give details: continued overleaf 12

15 6. Does your child have epilepsy?. If "yes", please give brief description of seizures (including how often) 7. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam? If yes has it been prescribed for emergency use in school? 8. Does your child have a bedwetting problem?. Is this a new problem? Is your child dry by day?. 9. Does your child have any bowel problems? If yes please give details Does your child have behaviour problems?... If "yes" please give details: Does your child have any known allergies?. If yes please give details and state if any emergency medication is required? Do you have any particular worries about your child? If "yes" please give details: Do you intend to be at the medical appointment?. If no do you still want your child to be seen and examined?... If you are unable to attend and you want your child to be seen can s/he be accompanied by teacher/classroom assistant, if necessary?..... Are you happy for the doctor/nurse to talk to the teacher about your child, if necessary? Do you consent to the doctor providing a relevant report to the Education & Library Board for the annual review of statement, if necessary?. Please state your current address if different from overleaf: Please state your contact telephone number(s).... Signature of Person with Parental Responsibility Date. 13

16 School Health Service Invitation to Medical Children s Services Directorate Recipient s Name Recipient's Address 1 Recipient's Address 2 Recipient's Address 3 Recipient's Address 4 Recipient's Postcode Date: To: The Person with Parental Responsibility You and your child are invited to attend an appointment with the school nurse and community paediatrician: In: School On: At: Your attendance would be greatly appreciated. Please complete the attached questionnaire and return it to school before the appointment. Yours faithfully, Clerical Officer 14

17 Protocol for Health Appraisals and Medical Examinations in Special M Schools and Learning Support Centres Special M Schools Dunfane Castle Tower Campus, Ballymena Rosstulla Jordanstown Learning Support Centres Moyle Primary School, Larne Larne High School, Larne Holy Trinity Primary School, Cookstown Cookstown Primary School, Cookstown Glenview Primary School, Maghera Rathenraw Primary School, Antrim Ballymoney Model, Ballmoney Ballysally Primary School, Coleraine Christie Primary School, Coleraine Harpur s Hill, Coleraine St Brigid s Primary School, Ballymoney General Comments 1. Children attending special M schools will have their health appraisal undertaken by the school nurse in advance of any medical examination as for children in mainstream schools 2. Children attending special M schools and learning support units may have an isolated learning disability or it may be part of a wider medical condition 3. Children may not be attending any specialist services 4. Provided consent is obtained, health appraisal by the nurse will take place in the school even in the absence of a parent 5. In the event of a carer not being present for the appointment, information will be shared using the standard letter Health Appraisal Outcome Special Schools and LSC 6. The location of any subsequent medical examination (if required) will be determined jointly by the paediatrician and the child s carer given that children may travel some distance to attend their specialist education provision and therefore carers may have difficulty attending appointments in school. 7. Where an appointment has been cancelled, this will be rescheduled as soon as possible 8. In the event of a pupil being absent or consent not having been obtained (for health appraisal), one further appointment will be offered the following 15

18 school year only. In the event of a health appraisal not taking place despite two invitations, the situation must be discussed with the paediatrician. School Nurse Health Appraisals - all P1 and Year 8 pupils and New Entrants 1. All P1 pupils and all new entrants who have not had a previous P1 health appraisal, will be offered an appraisal with the school nurse (universal school entrant health appraisal). 2. All Year 8 pupils will be offered an appraisal with the school nurse. 3. The CHS 24R will not be issued to pupils at these schools. Clerical staff should issue relevant questionnaire Special Needs Health Questionnaire Children with Statements together with CHS letter of invitation 4. School Nurse will discuss all children with the paediatrician for the school to determine the outcome of the health appraisal: a. There may be no indication for the child to be seen for long term review b. The child may require to be seen either at a local clinic or by the paediatrician in their area of residence. c. Where the paediatrican determines that a child requires an appointment he/she will be responsible for ensuring that an appointment is arranged/referral made to the child s area of residence 5. CHS 18R is completed by the nurse and returned to clerical staff for input onto CHS Where a medical appointment is required 1. Paediatrician will be responsible for organising the appointment at the most appropriate location this may require an appointment with a paediatrician in another locality 2. Paediatrician will make a handwritten record of the consultation and complete the CHS18R, ensuring it is returned to the relevant CHS clerical officer 3. Paediatrician will determine the need for further review and the frequency of same. 4. Information will be shared with the child s GP the exact format is yet to be determined - options include: a. Copy CHS18R b. Standard letter issued or c. Copy of file note (handwritten) 16

19 School Health Service Special Needs Health Questionnaire Children with Statements Name... Address School Date of Birth... GP Does your child have any medical conditions? If yes, please give details. 2. Is your child in good health at present?. If "no" please give details: Is your child on regular medication/treatment?... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 4. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 5. Do you suspect poor hearing?. If yes please give details: continued overleaf 6. Do you suspect poor vision? 17

20 If yes please give details: 7. Does your child have epilepsy?. If "yes", please give brief description of seizures (including how often) 8. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam? If yes has it been prescribed for emergency use in school? 9. Does your child have a bedwetting problem?. Is this a new problem? Is your child dry by day?. 10. Does your child have any bowel problems? If yes please give details Does your child have behaviour problems?... If "yes" please give details: Does your child have any known allergies?. If yes please give details and state if any emergency medication is required? Do you have any particular worries about your child? If "yes" please give details: Has your child previously attended another school? If yes please give details. Please state your current address if different from overleaf: Consent: I have read and understood the information accompanying this form and, on this basis (Please delete as appropriate) I agree/do not agree to the child named overleaf receiving the health checks, as described, from the school health team Signature: Date:. (Person with Parental Responsibility) Relationship to Child: Contact Tel No: 18

21 Protocol for Health Appraisals and Medical Examinations in Jordanstown Special Schools General Comments 1. Children attending Jordanstown have either a visual or a hearing impairment occasionally both, this may be an isolated condition or a symptom of a wider clinical condition 2. Children usually attend a relevant specialist in relation to their primary impairment and may also attend other specialist consultants 3. Children travel from across the Province and across the island of Ireland to attend the school (boarding facilities exist) 4. All NI resident children will have had a statement of educational need written and one of the components of this is the medical examination 5. Provided consent is obtained, health appraisal by the nurse will take place in the school even in the absence of a parent 6. In the event of a carer not being present for the appointment, information will be shared using the standard letter Health Appraisal Outcome Special Schools and LSC 7. The location of any subsequent medical examination (if required) will be determined jointly by the paediatrician and the child s carer given that children may travel some distance to attend their specialist education provision and therefore carers may have difficulty attending appointments in school. 8. Where an appointment has been cancelled, this will be rescheduled as soon as possible 9. In the event of a pupil being absent or consent not having been obtained (for health appraisal), one further appointment will be offered the following school year only. In the event of a health appraisal not taking place despite two invitations, the situation must be discussed with the paediatrician. School Nurse Health Appraisals - all P1 and Year 8 pupils and New Entrants 1. All P1 pupils and all new entrants who have not had a previous P1 health appraisal, will be offered an appraisal with the school nurse (universal school entrant health appraisal). 2. All Year 8 pupils will be offered an appraisal with the school nurse 19

22 3. The CHS24R will not be issued but the school nurse will review the list of all relevant new entrants, against their medical condition, to determine which questionnaire will be issued either Special School Questionnaire for Pupils with Visual Impairment or Specials Schools Questionnaire for Pupils with Hearing Impairment. CHS letter of invitation will also be issued 4. School Nurse will discuss all children with the paediatrician for the school to determine the outcome of the health appraisal: a. There may be no indication for the child to be seen for long term review b. The child may require to be seen either at a local clinic or by the paediatrician in their area of residence. c. Where the paediatrican determines that a child requires an appointment he/she will be responsible for ensuring that an appointment is arranged/referral made to the child s area of residence (the paediatrician will have a list of colleagues across the province to whom they can make referrals where indicated) 5. The CHS18R is completed by the nurse and returned to clerical staff for input onto CHS Where a medical appointment is required 1. Paediatrician will be responsible for organising the appointment at the most appropriate location this may require an appointment with a paediatrician in another locality 2. Paediatrician will make a handwritten record of the consultation and complete the CHS18R, ensuring it is returned to the relevant CHS clerical officer 3. Paediatrician will determine the need for further review and the frequency of same. 4. Information will be shared with the child s GP the exact format is yet to be determined - options include: a. Copy CHS18R b. Standard letter issued or c. Copy of file note (handwritten) 20

23 School Health Service Special School Questionnaire For Pupils with Visual Impairment Name... Address School. Date of Birth...GP Does your child have any medical conditions? If yes, please give details. 2. Is your child in good health at present? If "no" please give details: Is your child on regular medication/treatment?.... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 4. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 5. Do you suspect poor hearing?. If yes please give details: (continued overleaf) 21

24 6. Does your child have epilepsy?.. If "yes", please give brief description of seizures (including how often) 7. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam? If yes has it been prescribed for emergency use in school? 8. Does your child have a bedwetting problem?. Is this a new problem?. Is your child dry by day?.. 9. Does your child have any bowel problems?. If yes please give details Does your child have behaviour problems?.. If "yes" please give details: Does your child have any known allergies? If yes please give details and state if any emergency medication is required?. 12. Do you have any particular worries about your child?.. If "yes" please give details: Has your child previously attended another school? If yes please give details. Please state your current address if different from overleaf: Consent I have read and understood the information accompanying this form and, on this basis (Please delete as appropriate) I agree/do not agree to the child named overleaf receiving the health checks, as described, from the school Health team Signature: Date:. (Person with Parental Responsibility) Relationship to Child: Contact Tel No: 22

25 School Health Service Special School Questionnaire For Pupils with Hearing Impairment Name... Address School.. Date of Birth... GP Does your child have any medical conditions? If yes, please give details. 2. Is your child in good health at present?.. If "no" please give details: Is your child on regular medication/treatment?... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 4. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 5. Do you suspect poor vision?. If yes please give details: continued overleaf 23

26 6. Does your child have epilepsy?. If "yes", please give brief description of seizures (including how often).. 7. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam?.. If yes has it been prescribed for emergency use in school? 8. Does your child have a bedwetting problem?. Is this a new problem?. Is your child dry by day?.. 9. Does your child have any bowel problems?. If yes please give details Does your child have behaviour problems?... If "yes" please give details: Does your child have any known allergies? If yes please give details and state if any emergency medication is required?. 12. Do you have any particular worries about your child?.. If "yes" please give details: Has your child previously attended another school? If yes please give details. Please state your current address if different from overleaf: Consent I have read and understood the information accompanying this form and, on this basis (Please delete as appropriate) I agree to the child named overleaf receiving the health checks, as described, from the School Health Team Signature: Date:. (Person with Parental Responsibility) Relationship to Child: Contact Tel No: 24

27 Protocol for Health Appraisals and Medical Examinations in Thornfield House School and the Speech & Language Unit, Model Primary School, Ballymoney General Comments 1. Children attending a speech and language school or unit may have an isolated speech and language impairment or it may be a symptom of a wider clinical condition 2. Children may not attend any other medical consultant 3. Children may travel from across the Province to attend the special school 4. All children will have had a statement of educational need written and one of the components of this is the medical examination 5. Provided consent is obtained, health appraisal by the nurse will take place in the school even in the absence of a parent 6. In the event of a carer not being present for the appointment, information will be shared using the standard letter Health Appraisal Outcome Special Schools and LSC 7. The location of any subsequent medical examination (if required) will be determined jointly by the paediatrician and the child s carer given that children may travel some distance to attend their specialist education provision and therefore carers may have difficulty attending appointments in school. 8. Where an appointment has been cancelled, this will be rescheduled as soon as possible 9. In the event of a pupil being absent or consent not having been obtained (for health appraisal), one further appointment will be offered the following school year only. In the event of a health appraisal not taking place despite two invitations, the situation must be discussed with the paediatrician. School Nurse Health Appraisals - all P1 and Year 8 pupils and New Entrants 1. All P1 pupils and all new entrants who have not had a previous P1 health appraisal, will be offered an appraisal with the school nurse (universal school entrant health appraisal). 2. All Year 8 pupils will be offered an appraisal with the school nurse 25

28 3. The CHS24R will not be issued to these pupils. Clerical staff should issue relevant questionnaire Special School Health Questionnaire S&L Impairment together with CHS letter of invitation 4. School Nurse will discuss all children with the paediatrician for the school to determine the outcome of the health appraisal: a. There may be no indication for the child to be seen for long term review b. The child may require to be seen either at a local clinic or by the paediatrician in their area of residence. c. Where the paediatrican determines that a child requires an appointment he/she will be responsible for ensuring that an appointment is arranged/referral made to the child s area of residence (the paediatrician will have a list of colleagues across the province to whom they can make referrals where indicated) 5. The CHS18R is completed by the nurse and returned to clerical staff for input onto CHS Where a medical appointment is required 1. Paediatrician will be responsible for organising the appointment at the most appropriate location this may require an appointment with a paediatrician in another locality 2. Paediatrician will make a handwritten record of the consultation and complete the CHS18R, ensuring it is returned to the relevant CHS clerical officer 3. Paediatrician will determine the need for further review and the frequency of same. 4. Information will be shared with the child s GP the exact format is yet to be determined - options include: a. Copy CHS18R b. Standard letter issued or c. Copy of file note (handwritten) 26

29 School Health Service Special School Health Questionnaire Speech & Language Impairment Name... Address School:.. Date of Birth... GP Does your child have any medical conditions? If yes, please give details. 2. Is your child in good health at present?.. If "no" please give details: Is your child on regular medication/treatment?... (Include inhalers, nebulisers, catheters etc) If "yes" please give details in table below: Name Dose Time Given 4. Has your child been in hospital or attended a community clinic within the last year? If "yes" please complete the following: Hospital or Clinic attended Date of last appointment Reason for attendance Still attending? 5. Do you suspect poor hearing?. If yes please give details: 6. Do you suspect poor vision? If yes please give details: continued overleaf: 27

30 7. Does your child have epilepsy?. If "yes", please give brief description of seizures (including how often) 8. Has your child been prescribed rectal Diazepam (stesolid) or buccal Midazolam? If yes has it been prescribed for emergency use in school? 9. Does your child have a bedwetting problem?. Is this a new problem? Is your child dry by day?. 10. Does your child have any bowel problems? If yes please give details Does your child have behaviour problems?... If "yes" please give details: Does your child have any known allergies?. If yes please give details and state if any emergency medication is required? Do you have any particular worries about your child? If "yes" please give details: Has your child previously attended another school? If yes please give details. Please state your current address if different from overleaf: Consent I have read and understood the information accompanying this form and, on this basis (Please delete as appropriate) I agree/do not agree to the child named overleaf receiving the health checks, as described, from the school Health tea Signature: Date:. (Person with Parental Responsibility) Relationship to Child: Contact Tel No: 28

31 Health Appraisal Outcome Special Schools & LSC Date: To the Person with Parental Responsibility for: Name: D.O.B.: Address: School: Your child has had a health appraisal in school. The results are as follows: Hearing: Vision: Height: Weight: normal/see attached letter normal/see attached letter cms kgs I have discussed the detail of the health appraisal of your child with the paediatrician for the school who has decided that your child would/would not benefit from a medical appointment. Details of an appointment will be sent out in due course if this is required. Yours sincerely SCHOOL NURSE School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber» 29

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