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School Nursing (Wirral)
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Year 7 Student Health Assessment questionnaire (Wirral)
Year 7 Student Health Assessment questionnaire (Wirral)
Name of School
*
Please Select
Birkenhead High School Academy, Oxton
Birkenhead School, Oxton
Birkenhead Park
Calday Grange Grammar School, West Kirby
Co-op Academy Bebington High
Hilbre
Kilgarth School, Birkenhead
Mosslands
Oldershaw
Pensby
Prenton High School for Girls, Birkenhead
Ridgeway High School, Noctorum
South Wirral High School, Eastham
St Anselm's College, Birkenhead
St John Plessington Catholic College, Bebington
St Mary's College, Wallasey
The Observatory School, Prenton
Upton Hall School FCJ, Upton
Weatherhead High School, Wallasey
Weatherhead High School, Wallasey
West Kirby Grammar school for Girls
Wirral Grammar School for Boys, Bebington
Wirral Grammar School for Girls, Bebington
Woodchurch High School, Woodchurch
Your Name
*
Your date of birth
*
Month
Day
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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