Section1 Student Forenames: Last Name: Date of Birth: Place of Birth: Parental Address: Fathers Address if Different: Phone Number: Phone Number: Email Address: Email Address:
Name and Address of Current GP:
Does your child take any regular medication,
Does your child have any known allergies?
Is your child on the BUPA School Medical Insurance Scheme?
If no and you are using your own Private Health Insurance company please give the following information. Company Name Membership Number Please give name in which the policy is held, if held in the family name who is the main policy holder?
Has your child ever suffered from or consulted a doctor about any of the following? If YES please give details
ordinary childhood infections (i.e. chickenpox) b) Persistent cough, shortness of
breath, asthma, hay fever, sinusitis, tuberculosis or any other disease or the
murmur, or any other disease of the heart or circulation.
appendicitis, hernia or any other disease of the abdomen.
genitor-urinary system, such as cystitis or problems with menstruation. f) Any disorder of the glands such as
medication with tranquillisers or treatment by a psychologist or psychiatrist. h) Is there a history of an eating
i) Disorder of the eyes, ears or ears, or
any neurological disorder such as recurrent headaches or migraines?
hospitalised or had a general Anaesthetic? k) Does your child bed wet?
1) Please give full details of any past injury or disease of the spine, or other bones, joints, muscles or ligaments, in particular back pain, or any previous injuries related to dancing or exercise. It is in your best interest to give full details particularly of any recurrent injury so that the medical team can help you resolve the problem. 2) Has your child received any other medical advice, treatment, investigations or treatment in hospital or from a Doctor, or are you contemplating any such treatment, about any other condition not mentioned above. 3) Are there any immediate family members who have had or are suffering for any of the following (please circle): High Blood Pressure Asthma Diabetes Epilepsy
Please indicate the applicants relationship to the family member:
4) To the best of your knowledge and belief is the applicant now in good health? If not, please give full particulars and any additional information that you feel that we should know. Section 2 Consent for Medical Needs 1) I consent to my child being prescribed medication by the school doctor. 2) I consent to the school nurse administering appropriate Medication to my child. 3) I consent to a Houseparent when necessary and appropriate Administering medication to my child. 4) I consent to my child receiving first aid treatment from an Appropriately qualified member of staff. 5) I agree to authorise Elmhurst Medical Centre to approve such Medical treatment for my child as is deemed necessary in an emergency. Parent/Guardian Signature:______________________________ Date:___________________
Consent to the Administration of Medication. Please note that the administration of all medication at Elmhurst School is carefully monitored, if you have any concerns please contact the school Medical Centre
Drug Name and use Creams and Lotions Paracetamol – Tablet or liquid Yes / No Arnica – Cream:
Given for mild pain and to reduce temperatures.
Ibuprofen – Tablet or liquid Yes / No Witch Hazel – Lotion
Anti Inflammatory, used of muscular pain and reducing
temperatures. Will not be given to students with Asthma. Piriton – Tablets or Liquid Yes / No Benadryl – Cream
Antihistamine, helps to reduce allergic reactions, hay fever
and skin rashes. Will not be given to students with Epilepsy. Clarityn – Tablets Yes / No E45 – Cream
Antihistamine, once a day treatment for hay fever.
Strepsils – Lozenges Yes / No Vicks Vapo Rub. Lemsip – Powder Yes / No Olbus Oil
For treatment of colds. Will not be used with other
Used as an inhalation to ease the symptoms of catarrh.
paracetamol based drugs. Simple Linctus – Liquid Yes / No Deep Heat Rub
Helps to easse muscular strains and sprains.
Sudafed – Tablets Yes / No Biofreeze – Gel
Reduces nasal congestion associated with colds and
Helps to ease muscular strains and sprains.
sinusitis. Dioralyte – Powder Yes / No Fenbid 5% - Gel
Used for replacement of essential water and salts, for those
Ibuprofen based topical gel, used to treat muscular pain.
Will not be given to students with Asthma. Imodium – Tablets Yes / No Sun Tan Lotion Where possible please provide your child with their own. Joy Rides – Tablets Yes / No After Sun Lotion Where possible please provide your child with their own. Parental Signature:_____________________________________ Date:___________________________________ Print Name: ________________________________________________
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2009 H1N1 FLU VACCINE ADMINISTRATION RECORD The confidentiality of shared information is protected under state and/or federal law. Health Department records are subject to Wisconsin State Statutes, including but not limited to, Wisconsin State Stats 146.81-83, 51.30, 146.025. Since information in the Health Department records is protected under these statutes, only information that is permis