Medical form
information
Family name:
Given names:
Gender:
Date of birth:
DayMonth
Female
Male
Year
Nominated emergency contacts
Contact one
Name:
Relationship to student:
Home phone:
Mobile phone:
Country
Area
Local number
Country
Area
Local number
Area
Local number
Contact two
Relationship to student:
Name:
Mobile phone:
Home phone:
Country
Area
Local number
Country
Languages spoken:
Information which may be crucial in an emergency
Are you currently on any medication?
Yes
Please list the name of any medication and frequency:
No
Known reactions to any medication:
Please state which:
AllergiesYesNo
Wears glasses/contact lenses:
Date of most recent Tetanus shot:
DayMonth
Yes
No
Year
The following health conditions may be of concern:
Please tick any that apply
Asthma
Congenital anomalies
Convulsions/epilepsy(seizures)
Diabetes
Recurring ear infections
Hearing difficulties
Orthopedic problems
Visual/spatial problems
Frequent headaches
Post-operative condition
Others (specify)
Heart problems
Rheumatic fever
Kidney/urinary infections
Skin problems
Menstrual problems
Please comment on any ticked items:
Has your child ever had an operation?
Yes
No
Tuberculosis
Why and when?
Detail any limits on physical activity:
Required for admission:
Current Tuberculin Skin Test
TB skin test type:
Result:
Physical:
BCG Inoculation Record within the past 5 years
Date:
BCG Vaccination:
DayMonth
Year