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School Nursing (St Helens)
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Pupil Health Assessment Questionnaire (Year 6) – St Helens
Pupil Health Assessment Questionnaire (Year 6) – St Helens
Your answers to the following questions are confidential
Name of School
*
Please Select
Allanson Street Primary School, Parr
Ashurst Primary School, Blackbrook
Bleak Hill Primary School, Windle
Broad Oak Community Primary School, Broad Oak
Carr Mill Primary School, Moss Bank
Chapel End Primary School, Billinge
Corpus Christi RC Primary School, Rainford
The District CE Primary School, Newton-le-Willows
Eaves Primary School, Sutton
Eccleston Lane Ends Primary School, Eccleston
Eccleston Mere Primary School, Eccleston
Garswood Primary and Nursery School, Garswood
Grange Valley Primary School, Haydock
Haydock English Martyrs' RC Primary School, Haydock
Holy Cross RC Primary School, St Helens
Holy Spirit RC Primary School, Parr
Legh Vale Primary School, Haydock
Longton Lane Community Primary School, Rainhill
Lyme Community Primary School, Newton-le-Willows
Merton Bank Primary School, Merton Bank
Newton-le-Willows Primary School, Newton-le-Willows
Nutgrove Methodist Primary School, Nutgrove
Oakdene Primary School, Rainhill
Parish CE Primary School, St Helens
Queen's Park CE/URC Primary School, Dentons Green
Rainford Brook Lodge Community Primary School, Rainford
Rainford CE Primary School, Rainford
Rectory CE Primary School, North Ashton
Rivington Primary School, Dentons Green
Robins Lane Community Primary School, Sutton
St Aidan's CE Primary School, Billinge
St Anne's RC Primary School, Sutton
St Ann's CE Primary School, Rainhill
St Austin's RC Primary School, Nutgrove
St Bartholomew's RC Primary School, Rainhill
St James's CE Primary School, Haydock
St John Vianney RC Primary School, Thatto Heath
St Julie's RC Primary School, Eccleston
St Mary & St Thomas' CE Primary School, St Helens
St Mary's RC Infant School, Newton-le-Willows
St Mary's RC Junior School, Newton-le-Willows
St Mary's RC Primary School, Billinge
St Mary's RC Primary School, Blackbrook
St Peter and St Paul RC Primary School, Haresfinch
St Peter's CE Primary School, Newton-le-Willows
St Teresa's, Devon St
St Theresa's RC Primary School, Sutton
St Thomas of Canterbury RC Primary School, Windle
Sherdley Primary School, Sutton
Sutton Manor Community Primary School, Sutton
Sutton Oak CE Primary School, Sutton
Thatto Heath Community Primary School, Thatto Heath
Wargrave CE Primary School, Newton-le-Willows
Willow Tree Primary School, Sutton
Home schooled
Your Name
*
Your date of birth
*
Day
Month
Year
Do you have any worries about your health (eg asthma, diabetes, epilepsy)?
Yes
No
If yes, please use the comment box to add any information about your worries.
Have you seen a dentist in the last year?
Yes
No
Please ask your parent or carer to make an appointment for you as soon as possible.
Have you had your eyes tested by an optician in the last year?
Yes
No
Please ask your parent or carer to make you an appointment as soon as possible. Eye tests are free for children.
Do you have any worries about how your body is changing? (eg menstrual periods (girls), voice changes (boys), hair growth).
Yes
No
If yes, please use the comment box to add any information about your worries.
Do you have any worries about your height or weight?
Yes
No
If yes, please use the comment box to add any information about your worries.
Do you have any worries about your feelings? (eg sad, angry, lonely, scared, anxious)
Yes
No
If yes, please use the comment box to add any information about how you are feeling.
Do you have any worries about your behaviour? (eg being too active, shouting at people, running off, finding it difficult to concentrate on one task, forgetting things)
Yes
No
If yes, please use the comment box to add any information about your worries.
Do you have a trusted adult to talk to at home or school?
Yes
No
If no, please use the comment box to add any information about how this makes you feel.
Would you like to speak to a member of the school health team to discuss any feelings, worries or concerns you may have about your health and wellbeing?
Yes
No
If yes, please use the comment box and let us know how the school nursing team can help you.
Confidentiality
*
Unless you give permission, we will not pass on anything you say to anyone else, like parents, teachers, or other students – except in extreme circumstances eg if the health, safety or welfare of you or someone else who is at significant risk.
If we did need to tell someone about something you have told us, we would always try to speak with you first. For our safety and yours we hold information that you tell us on electronic records that can be seen by other healthcare professionals who all follow the same confidentiality rules – this can include your doctor. Records are kept for future use.
I agree that I have read the confidentiality above.
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