STUDENT'S MEDICAL REPORT

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STUDENT'S MEDICAL REPORT

The school requires up-to-date, accurate medical information so we are able to care for your child appropriately.

Complete and send the form below.
A copy of the form can be downloaded Student's Medical Record Form >>

Please supply as much information as possible. If you have any concerns regarding your child’s health please do not hesitate to call Jo Eberly, First Aider: 09 483-9039 xt 836.

* Indicates required field

Student's Name *

Date of Birth *

Name of Doctor *

Doctor's Phone *

Name of Dentist (see below for Lumino Mobile Dental Clinic) *

Does your child have any of the following? Tick appropriate box and add any details.

Asthma *

Yes No

Allergies / Hay Fever *

Yes No

Please list *

Anaphylactic or severe reaction? *

Yes No

Please describe *

Diabetes *

Yes No

Heart Condition *

Yes No

Does your child take any medications? *

Yes No

Please list *

Does your child currently have, or in the past, has had any other medical condition or surgery? *

Yes No

Please describe *

Are there any learning or behavioural concerns the school should be aware of? *

Yes No

Please describe *

Does your child currently have, or in the past, has had any mental issues? e.g. depression or anorexia nervosa *

Yes No

Please describe *

Are their vaccinations up to date? *

Yes No

Do you give your child permission to be given Paracetamol (Panadol) if required? *

Yes No

Do you give permission for your child to see the Public Health Nurse at school? *

Yes No

Would you like your child to be seen by the free Lumino Mobile Dental Service (Term 1)? If yes, you MUST complete a Lumino Enrolment Form. (Available at our reception desk). *

Yes No

I declare that the above information is true and accurate.

Parent/Guardian Name *

Date *

SEND