<> Uollail fora duos4i GEMS World Academy HEALTH QUESTIONNAIRE information provide herein wil rm confidential by at att. Grade: Student's name Please take time answer the following auestion: by encircle YES or NO. 1. Are worried about your cil 2) Hearing - Yes No sight - Yes No © Spe Yes No 2. Does your child wear a) Glasses - Yes Nob) Hearing aid/s. Yes No any appliance- Yes No oF Prost oes your child have any problems requiring GP or Hospital attention? Yes No If yes, please write detail: 4 Has your child seen 2 medical speciaist? Yes No erence nena geen ee Eee 5. Does yourchilé have allergies? -Yes._—No. yes, please write details of allergies, reactions, severty and when was the last allergic reaction? 6. Isyour child taking regular medication/s? Yes No Hye, please write details: 7. Does you child have any problem which might affect full participation in PE orsports? Yes No yes, please write details: (Your answer here will be disclosed to the PE teacher for safety reasons) 8. Have any other concerns about your child'shealth? Yes NO It yes, please write detail Parents Name and signature Date