Taipei American School
Student Health Record
Student Name________________________________________________________ Date of Birth __________________________ Grade _____________
Student ID Number____________________________
Please fill in the Student Health History and Vaccination Record. A licensed physician must review these charts. The physician must also complete the Physical
Examination Form and review the Sports Physical History (for middle and upper school students only). The school will require a copy of original vaccination records.
Student Health History
Yes
No
Yes
ADD/ADHD
Bone Fractures
Allergies
to_____________
(food, medication, etc.)
Asthma
Diabetes
Epilepsy/Seizure
Disorder
Frequent Ear Infections/
Hearing Problem
Back Problems or
Scoliosis
No
Yes
No
Yes
Gastrointestinal
Disorder
Heart Disorder
Kidney Disorder
Migraine Headache/
Frequent Headache
Skin Problem
Blood Disorder ( G6PD,
Anemia)
Psychological /
Developmental Disorder
(Anxiety, Bipolar,
Depression)
No
Vision Problems
Medications taken on a regular basis:
Other illnesses, hospitalizations, surgeries, or serious injuries?
Physician, please comment on all “yes” answers:
Vaccination Record:
Type of Vaccination
Oral (OPV)
Polio
Inactivated (IPV)
Diphtheria, Pertussis, Tetanus (DPT/DTaP)
/ /
(2 months)
/ /
(4 months)
Date Received ( mm/dd/yy)
/ /
/ /
(6 months)
(18 months)
/ /
(age 4-6)
/ /
(2 months)
/ /
(2 months)
/ /
(4 months)
/ /
(4 months)
/ /
(18 months)
/ /
(18 months)
/ /
(age 4-6)
/ /
(age 4-6)
/ /
(15 months)
/ /
(booster after age 10)
/ /
(age 4-6)
/ /
(6 months)
Tetanus Booster
(Tdap/Td/DT)
Measles/Mumps/Rubella (MMR)
Hepatitis B (3 dose)
/ /
( birth )
/ /
(2 months)
/ /
(12 months)
Varicella (Chicken Pox or natural disease)
Physical Examination Form
Height_________ Weight___________Blood Pressure____________Pulse___________Visual Acuity: Right20/____Left20/____
Medical
Normal
Neck
Eyes (pupils) ENT
Teeth
Chest
Lungs
Heart
Abdomen
Abnormal Findings (Physician to comment on
all abnormal findings)
Medical
Normal
Abnormal Findings (Physician to comment on
all abnormal findings)
Hernia
Neurologic
Skin
Spine/Back
Shoulders/Upper Extremities
Lower Extremities
On the basis of this examination, this student may participate in the school program, physical education class, and interscholastic sports. Physicians, please mark
below.
CLEARED WITHOUT RESTRICTIONS
CLEARED WITH THE FOLLOWING NOTATION:______________________________________________________________
NOT CLEARED FOR PARTICIPATION Reason:_______________________________________________________________________________________________
Physician’s Signature and Stamp______________________________________________Date_________________________________
As of February 10, 2014
Sports Physical History
For Middle School and Upper School Students Only
Instructions: All new middle and upper school students must complete the Sports Physical History prior to enrollment. Returning students in grades 6 and 9 must
complete the Sports Physical History. This form must be reviewed and signed by a physician.
Student Name_______________________________________Date of Birth________________________Grade___________________
Yes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
No
Health History Questions
Have you ever had any sports injuries requiring treatment by a physician?
Do you have any organs missing?
Have you ever had chest pain, dizziness, fainting, or passing out during or after exercise?
Do you tire more easily or quickly than your friends during exercise?
Have you ever had any problems with your blood pressure or your heart?
Have any close relatives had heart problems, a heart attack, or sudden death before the age of 50?
Have you ever fainted, had convulsions, seizures, or severe dizziness?
Do you have frequent, severe headaches?
Have you ever had a “pinched nerve”?
Have you ever been “knocked out” or “passed out”?
Have you ever had a neck or head injury?
Have you ever had heat exhaustion, heat stroke, heat cramps, or similar heat-related problems?
Have you ever had an asthma attack, trouble breathing, or coughing during or after exercise?
Do you wear eyeglasses, contact lenses, or protective eye wear?
Have you had any problems with your eyes or vision?
Do you wear any dental appliance such as braces, bridge, plate or retainer?
Have you ever had a knee, ankle, or joint injury?
Have you ever had a broken bone or fracture?
Have you ever had a cast, splint, or had to use crutches?
Do you use special equipment for competition (pads, brace, neck roll, etc.)?
Are there any health concerns regarding your weight?
FEMALES: Have you had any menstrual problems?
Do you have any medical or health concerns which would inhibit you from participating in sports or P.E.?
Physician: Please remark on all “yes” or “abnormal” answers.
Physician Signature and Stamp________________________________________Date:_____________________
As of February 10, 2014