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STUDENT HEALTH RECORD FOR REGISTRATION
Name _____________________________________________________________________________________________________ M F Date of birth _______________________________ Grade entering this year ______________________________ Parent’s/Guardian’s name _____________________________________________________________________________________________ Address _______________________________________________________________________________________________________________ Home telephone no. _________________ Cellular phone no. _________________ Office telephone no. _________________ In case of emergency call ____________________________________________________ Telephone ___________________________ Physician’s name ____________________________________________________________ Telephone ___________________________ In case of emergency, I authorise the school to use its judgment, if no authorised person listed above can be reached SIGNIFICANT MEDICAL HISTORY
Disease/Condition
immunization records or complete the table below.
Vaccination/Immunization
Allergies: ____________________________________________ _______________________________________________________ (Please specify if your child has specific medication and send it with dosage noted) Surgery ______________________________________________ _______________________________________________________ STUDENT HEALTH RECORD FOR REGISTRATION continued
Emotional or mental patterns of which the school should be aware of (Phobias, Anxieties, etc.) _______________________ Ethnic/Nutritional/Religious customs (helpful for field trips) __________________________________________________________ Most recent physical exam ____________________________________________________________________________________________ Medication your child takes on a regular basis _________________________________________________________________________ Restrictions on Physical Activity ________________________________________________________________________________________ BLOOD TYPE ________________________________ Group ___________________________ Rho ______________________________ COMMENTS ___________________________________________________________________________________________________________ CONSENT FOR “OVER THE COUNTER” MEDICATIONS
I give permission for my child, __________________________________________________________________________ , to receive anymedication I have indicated here below as deemed necessary by the school nurse. I understand that genericequivalent medications may be used in place of brand-name items.
PLEASE CHECK ANY “OVER THE COUNTER” MEDICATIONS YOU WISH TO BE MADE AVAILABLE TO YOUR CHILD
UNDER NURSING DISCRETION, DOSAGE DETERMINED BY AGE AND/OR WEIGHT
For headache/fever/muscle aches, menstrual cramps

Ibuprofen (like Advil, Motrin) – best for menstrual cramps, muscle/bone pain, For mild allergic reactions (such as hives, seasonal allergies)

For mild cold symptoms

For mild stomach discomfort

For mild skin irritation (insect bites, minor rashes, abrasions)

I do not want any medication given to my child in school
I understand that the above medications I have checked will be administered by the school nurse, or herdesignee.
Year ______________________________________________________________________________ Signature __________________________________________________________________________ _______________________________

Source: http://dev.isps.edu.tt/wordpress/wp-content/uploads/2012/12/health-record.pdf