ND medical form English by lSU30ve4

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									                                      Notre Dame Schools
                                               Medical Form
Name:          ……………………………                          ……………………………                        ………………………………
               (First name)                         (Father's name)                   (Family name)


Grade:         ……………………….                       Date of Birth: …./.…/…….. Gender: M                       F

Address: …………………………………………………….…………… Home phone: …………………….
             …………………………………………………….…………… phone: …………………….
Emergency contact:                   Mobile
   (Other than parent's)



In order to keep an up-to-date medical record on your child, it would be very much appreciated if you answer the
following questions and attatch a vaccination report.



Does your child suffer from any of the following                                 Has your child suffered from any of
conditions:If Yes, to what?(food, drugs etc.)                                    the following illnesses:

                  Yes          No        Other Family Member                                               Yes     No

Asthma                                                                           Measles
Diabetes                                                                         German Measles
Epilepsy                                                                         Hepatitis
Hay Fever                                                                        Mumps
Tuberculosis                                                                     Chicken Pox
Eczema                                                                           Whooping Cough
Allergies                                                                        ……………………….…
…………..                                                                           ………………….………


Does your child wear glasses? …………………………………………………………...…………………………….……



Is there a history of colour blindness in your family? ………………………………………...……………………….…..

Does your child have difficulty in hearing? ………………………………….……………………...………………….……

Has your child ever been hospitalized? If so where, when, and what for ?………………………….…………………...

……………………………………………………………………………………………...……………….……………………

Has your child ever had an operation? If so where, when, and what for ?…………………….…….…………………...


……………………………………………………………………………………………...……………….……………………




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                           Participation in Extra Curriclar/Physical Activities
                                                        Yes               No                        Remarks
Competetive Sports?

Physical Eduication?

Any Physical Limitation?

Any Special Assistance Needed?



If your child is taking a prescribed course of tablets or medicine and has to take it during school hours, would you please
stress to your child the importance of bringing the medicine to the School Physiician first thing in the morning. It can then
be collected from the doctor before going home. Please write clearly your child's name, class and time of medication.

MEDICINES ARE NOT TO BE KEPT WITH CHILDREN


                                           Authorizations                                                     Yes     No


Permission to give non-prescribed medications: (e.g. Tylenon)

Permission to administer first aid:

Permission to admit to hospital in extreme emergency:




                                                                               Parent's Signature………………………....




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