Medical Questionnaire and Dietary Requirements

Using the form below, please share any relevant medical conditions or dietary requirements. The safety of our students is paramount to Focused Future, and by filling in this form you are helping us keep every student as safe as possible. The privacy of our students is very important to us. For details of our privacy policy see here.

Student Name

First Name

Last Name

Do you have any medical conditions we should be made aware of?

Yes

No

If yes, please specify:

Medical Condition/Allergy: Severity: Medications/Treatments: Additional Comments:

Do you carry any emergency medications (e.g. EpiPen)?

Yes

No

If yes, please specify:

Medication Name: Dosage: Location where medication is usually kept:

Do you have any specific dietary restrictions or allergies we should be made aware of?

Yes

No

If yes please specify:

Lunch preferences

If you have any dietary preferences (i.e. not allergies or restrictions) please let us know here.

If you have any further information you would like to disclose please let us know here:

Medical Questionnaire and Dietary Requirements

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