APPENDIX C3 CONFIDENTIAL STUDENT MEDICAL INFORMATION AND CONTACT DETAILS
UPDATE - COMPULSORY
This information needs to be provided by the parent and updated for every medium/high risk trip. It should be
completed while considering the specific details of the trip provided by the school. [This can be in the form of a print
out from a student’s medical information with a request for updating]
C3.1 Background details
Student Name
Age
Address
Birth Date
Year/class
School
Gender
Parent’s Phone (Work)
Parent’s Phone (Mob)
Phone (Home)
Other emergency contact name
Relationship to student
Emergency contact phone
Hong Kong ID number
Passport number
Nationality (by passport*)
(If under 11 years old *)
Parent’s Name
* Passport numbers are required for all students not in possession of a Hong Kong I.D. card. This data is
required for the use of emergency helicopters or other related government service providers.
Please check carefully that the following medical information is up to date and inform of
any changes.
C3.2 Medical conditions (not including asthma and allergies)
Does your child have any of the following medical conditions that may require EMERGENCY
care?
Medical condition
Anaemia or other blood disorder
Diabetes
Diagnosed Anorexic or Bulimic
Difficulty in hearing or vision
Dizziness/Fainting spells
Epilepsy (convulsions)
Frequent headaches
Frequent nosebleeds
G6PD
Heart Problems (e.g. abnormal heart beat)
High or Low Blood Pressure
Illness when exposed to high temperature
Kidney Disease or bladder problems
Movement difficulty (arthritis, injury)
Phenylketonuria
Previous hospitalization or surgery
Psychological condition
Rare Blood Type
Rheumatic fever
Skin condition (e.g. eczema)
Tuberculosis/respiratory disorder
Other
Yes
No
If Yes give further details
C3.3 Immunisations
Has your child had the following immunizations? If Yes, indicate date
Tetanus
Yes / No
Hepatitis A
Yes / No
Hepatitis B
Tuberculosis (BCG)
Others
Yes / No
Yes / No
Yes / No
If Yes, give details
C3.4 Background allergies
Does your child suffer from any allergies?
Does your child see a doctor about their allergies?
*If YES – please provide name and contact details
for Doctor
When did the last allergic reaction occur?
What are they allergic to?
How would you rate the severity of your child’s
allergic reactions?
YES / NO
YES*/NO
Has hospitalization occurred because of a reaction?
Date of last hospitalisation
Describe what happens during a reaction
YES / NO
Mild with
no change
of activity
needed
Moderate
with a
need for
slight
changes
of activity
Moderate
with the
need for
immediate
change to
activity
Severe
with the
need for
medical
attention
In the event of a reaction, what actions are necessary
Name of allergy medication
Dose and route of administration
C3.5 Asthma
Does your child suffer from asthma?
Does your child see a doctor about their asthma?
*If YES – please provide name and contact details
for Doctor
When did the last asthma attack occur?
How many attacks of wheezing has your child had
in the last 12 months?
What triggers the asthma episodes?
When did the last asthma attack occur?
Is your child’s sleep disrupted due to wheezing?
Name of asthma medication
Dose and how the dose is administered
YES / NO
YES*/ NO
None
Never
1-3
4-12
Sometimes
more than
12
Often
C3.6 Other conditions
Does your child have any other condition that may affect their schooling or trips?
Please provide details:
YES / NO
C3.7 Medications
Does your child take any medications?
List the medicines
YES / NO
If YES, please give additional information (e.g.
dosage, frequency and other information useful to
the school)
C3.8 Safety in and around water
Is your child a confident swimmer?
Can your child keep afloat in water?
Can your child swim at least 50 metres fully clothed?
YES / NO
YES / NO
YES / NO
C3.9 Dietary information
Please outline below any special dietary requirements of your child and how best they should be catered
for
C3.10 Declaration
I have completed this medical form accurately, truthfully, and to the best of my knowledge as of today’s
date. I understand that it is my responsibility as a parent to inform the school of any previous or new
health problems or injuries and I am aware that if I have not, the school cannot be held responsible for
the consequences.
The school will endeavor to contact the parent or emergency contacts should your child be ill or
injured. However, if for any reason there is an emergency, I hereby give consent and full authority for
the staff or agents of the school to arrange for and consent to any medical treatment or hospitalisation
for my child / guardian while s/he is in the care of the school. I further authorise these staff members to
enter into and execute, on my behalf, such documents or consents as may be required by Medical
Practitioners, Health Care Professionals or Hospitals for such purposes.
Name of Parent / Guardian ________________________________
Signature of Parent / Guardian _____________________________
Relationship to student ________________________
Print name of student _________________________
Date _____________________________________