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    Medical Form

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    Honey Ali
    This document contains a student health information form for Cambridge Heights School in Sagar. The form collects information about a student's name, age, blood group, birthdate, gender, address, contact details, known allergies or medical conditions, asthma status, dietary requirements, immunization history, and provides consent for medical treatment. Parents are asked to disclose any food or environmental allergies, hospitalizations due to reactions, asthma medication, additional medical issues, eyeglasses use, travel sickness, bedwetting, and special dietary needs.

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    Download as DOCX, PDF, TXT or read online from Scribd

    Medical Form

    Uploaded by

    Honey Ali
    26 views2 pages
    This document contains a student health information form for Cambridge Heights School in Sagar. The form collects information about a student's name, age, blood group, birthdate, gender, address, contact details, known allergies or medical conditions, asthma status, dietary requirements, immunization history, and provides consent for medical treatment. Parents are asked to disclose any food or environmental allergies, hospitalizations due to reactions, asthma medication, additional medical issues, eyeglasses use, travel sickness, bedwetting, and special dietary needs.

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    Medical Form.docx

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    This document contains a student health information form for Cambridge Heights School in Sagar. The form collects information about a student's name, age, blood group, birthdate, gender, address, contact details, known allergies or medical conditions, asthma status, dietary requirements, immunization history, and provides consent for medical treatment. Parents are asked to disclose any food or environmental allergies, hospitalizations due to reactions, asthma medication, additional medical issues, eyeglasses use, travel sickness, bedwetting, and special dietary needs.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    26 views2 pages

    Medical Form

    Uploaded by

    Honey Ali
    This document contains a student health information form for Cambridge Heights School in Sagar. The form collects information about a student's name, age, blood group, birthdate, gender, address, contact details, known allergies or medical conditions, asthma status, dietary requirements, immunization history, and provides consent for medical treatment. Parents are asked to disclose any food or environmental allergies, hospitalizations due to reactions, asthma medication, additional medical issues, eyeglasses use, travel sickness, bedwetting, and special dietary needs.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    CAMBRIDGE HEIGHTS SCHOOL, SAGAR

    STUDENT HEALTH INFORMATION


    Student’s name: Age: Blood group:
    Year/Class: Birth Date: Gender:
    Address: Phone (Res.):
    Parent (Office):
    Parent (Mobile):
    *If none of the above is available in an emergency, Please contact:
    Name: Relationship:
    Contact No. :
    Known allergies/ medical conditions:

    My Child has had the following: (Please tick)


    Allergy to Name of allergen Severe Anaphylaxis/ Slight Medication None
    Foods
    Insects
    Drugs
    Animals
    Grasses, pollen
    Other
    Has hospitalization occurred because of a reaction: (Yes/No):
    Date:
    Asthma:
    Does your child suffer from Asthma? (Yes/No): Mild: Attacks are rare, limited mostly to tightness and wheezing.
    Moderate: Occasional attacks which can be self-managed using
    If ‘Yes’ please indicate how severe your child’s Asthma is: prescribed medication.
    Severe: Attacks are regular, severe and have required hospital
    treatment.
    Details of medication administered:
    Additional medical information
    Frequent nose Psychological Hearing Contact Travel Bed wetting Others
    bleed condition impairment lens/glasses sickness (Yes/No)
    (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)

    Please provide the date of the last tetanus injection


    Administered to your child.
    Dietary information
    Please outline any special dietary requirements of your Vegetarian Non-
    child and how best they should be catered to on an vegetarian
    excursion / trip. Vegan
    I have completed this medical form accurately, truthfully, and to the best of my knowledge as of today’s date. I understand that
    it is my responsibility to inform the school of any new medical condition or change in this information. I hereby give consent and full
    authority for the staff or agents of the school to arrange for and consent to any medical treatment or hospitalization for my child/
    guardian while s/he is in the care of the school. I further authorize these staff members to enter into and execute, on my behalf,
    such documents or consents as may be required by medical practitioners, health care professionals or hospitals for such purposes.
    Name of parent/guardian Relationship to
    and signature the student:
    Name of the student Date

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