Ras health form

Student Name ______________________________________________________

Tuberculosis Screening is required for Admissions and must be updated every two years: Please indicate at least one:
Mantoux or Tine Skin Test within past 2 years: Type ___________ Chest X-Ray (if previous positive reaction) within past 1 year: Does your child have any present il nesses ________ Yes ________ No _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Past history of:
Does your child suffer from any al ergies? _________Yes _________No Reaction: _______________________________________________________________________________________________________ Does your child have a history of asthma? ________Yes _______No Does he/she carry an asthma inhaler? ________Yes _________No Doers your child wear glasses or contact lenses _________Yes _________Noo Does your child have trouble hearing or use a hearing aid? _________Yes _________No Is your child on daily medication? _________Yes _________No Please list the name of the medications and the time/frequency required: ____________________________________________________ Is there any health condition that the school should be aware or any limitations on your child’s physical activity? _______________________________________________________________________________________________________________ Students may not receive medication unless written permission is signed by a parent or guardian. Parents of elementary students wil be contacted before any medication is given by signing below: 1. I attest that al the above information is accurate. 2. I hereby give permission to the school to administer the fol owing medications to my child if deemed necessary by the
school nurse: TylenolPanadol – IbuprofenAspirinAntacid Sudafed
(Please cross out (x) any medication NOT to be given to your child)
3. I hereby give permission for emergency measures to be initiated in case of accident or sudden il ness with the Parent Signature __________________________________________________ Date _________________________________________ IMMUNIZATION RECORD
All students, as a condition for admission, must be current on their childhood immunization schedule. At a minimum this shal include Polio, Diptheria, Pertussis, Tetanus, Measles, Mumps, Rubel a and Hepatitis B. This requirement can be waived only for health reasons or religious convictions, documented by a letter from the student’s physician describing the student’s health exemption or with a sworn affidavit from the parents attesting to their religious beliefs.

(To be completed by Licensed Physician, Nurse Practitioner or Physician’s Assistant)
______________________________________________________________ Examination completed by: _________________________________________________________________________________________ Printed Name Ttile _________________ ___________________________________________________________________________________________

Source: http://www.raffles-american-school.edu.my/images/RAS-Image/RAS%20Health%20Form.pdf


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