Student Health Information Form (newapplicant)

Name : ------Birth Date :------
Last / First / Middle / DD /MM /YY
Mother’s Name : …………………………………………….. / Father’s Name : ………………………………………………..
Home Phone : ……………………………………………………. / Father’s Employer : ……………………………………………
Mother’s Mobile : …………………………………………….. / Father’s Mobile : ……………………………………………….
Mother’s Work Phone : ……………………………………. / Father’s Work Phone : ………………………………………
Emergency Contact Person (if parent can not be reached) :
Name: ……………………………………………………… / Home phone: ………………………… / Mobile phone: …………………………….
Name: ………………………………………………………. / Home phone: ………………………… / Mobile phone: …………………………….
Family Doctor’sName:………………………………………………………………………….. Phone: ……………………………..
Hospital: …………………………………………………………………………………………… File No: ………………………
Please enclose a clear copy of the updated student immunization record.
Past Childhood Disease:
Chicken Pox
Measles
Mumps
German Measles (Rubella )
Other ………………………………………………………
Does your child have any of the following?
(if yes , please explain below , or attach a paper with explanation )
Condition / No / Yes / If yes please explain
Heart Disease
Diabetes
Special Care Plan for Diabetes
Hypertension / Hypotension
Hearing Difficulty
Asthma
Special Care Plan for Asthma
Musculoskeletal
Severe Headache
Anemia / Any Blood Disease
Vision Difficulty
Fainting Spell / Disease
Convulsion /Epilepsy
Glasses / Contact Lenses
Nose Bleeds
Speech Difficulty
Allergy
Specific Allergy:
Type of Reaction:
Required Response:
Any condition that restricts physical activity
Any special diet
Any particular medication that is required to be at school
According to ALS policy, the school is required to obtain your permission before the school doctor can administer any medicine to your child. We ask that you sign the permission slip below to identify those over the counter medications that you are willing to allow the school doctor to administer.
The ALS school doctor has permission to administer to my child, ……………………………………………those categories of over the counter medications checked off below.
Signature: ……………………………………………………………..
Medicine Name / No / Yes
  1. Analgesics (i.e. Panadol, Brufen, Tempra )

  1. Local analgesic ( Reparil Gel , Voltaren Emulgel )
/ Yes
  1. Antacid (i.e. Renne , Zantac )

  1. Spasmolytic (i.e. Buscopan )

  1. Antihistamines (i.e. Zyrtec , Claritin)

  1. Local antihistamine ( i.e. Fenistil Gel )

If your child has asthma we strongly encourage you to send an extra inhaler or medicine to be kept in doctor’s office. Please label it with the student name, grade and dose.
We understand that at certain times it is necessary for students to take medication at school other than the ones listed above and we are happy to accommodate this. However, in order to do so we require the following information:
Student name
Grade
Name of medication
Dose
Time to be given
Reason for giving
How long it is given for.
Of course, if we have any concerns or questions we won’t hesitate to contact you. Thank you for your cooperation in this matter.
I give permission for my son / daughter to be treated for minor ailments and to receive basic first aid in the school clinic as needed. I also give permission for emergency treatment and transportation to King Khalid University Hospital (the nearest hospital) Emergency Room if necessary. I hereby grant the school full authority to act in loco parentis for my child in case of emergency.
Signature:………………………………………………………………………………………. / Date: ……………………………………….
I ……………………………………..………………..verify that information given above is correct and the school will be informed in writing regarding any changes to the above information .
Signature: ……………………………………………………….

Updated 12/07/2010