Ministry of Health & Wellness / Ministry of Education Youth

and Information School Health Programme

STUDENT’S MEDICAL REPORT
Part A: To be completed by the Parent/Guardian

NAME OF SCHOOL: __________________________________________________

ACADEMIC YEAR: ______________
PERSONAL DATA
STUDENT’S NAME (first, middle, last): ________________________________________________
DATE OF BIRTH: ___________________ AGE:_______YRS SEX: M F
dd/mm/yyyy
ADDRESS:___________________________________________________________________________
_____________________________________________________________________________________

FAMILY DOCTOR OR HEALTH CENTRE: _______________________________________________

NAME OF MOTHER: _______________________________________________________

ADDRESS: (H)________________________________________________________________________
ADDRESS: (W)_______________________________________________________________________
TELEPHONE NO: (W)___________________ (H) __________________(Cell)_________________
EMAIL ADDRESS:_________________________________________

NAME OF FATHER: _______________________________________________________

ADDRESS: (H)________________________________________________________________________
ADDRESS: (W)_______________________________________________________________________
TELEPHONE NO: (W)___________________ (H) __________________(Cell)_________________
EMAIL ADDRESS:_________________________________________

NAME OF GUARDIAN OR PERSON WITH WHOM THE CHILD LIVES (if different from above):
_______________________________________________________ RELATIONSHIP: ________________
ADDRESS: (H)________________________________________________________________________
ADDRESS: (W)_______________________________________________________________________
TELEPHONE NO: (W)___________________ (H) __________________(Cell)_________________
EMAIL ADDRESS:_________________________________________

EMERGENCY CONTACT INFORMATION (Persons to be contacted if parents cannot be reached)

1) NAME:______________________________________ RELATIONSHIP________________________
ADDRESS: __________________________________________________________________________
TELEPHONE NO: (W)___________________ (H) __________________(Cell)_________________
EMAIL ADDRESS:_________________________________________
2) NAME:______________________________________ RELATIONSHIP________________________
ADDRESS: __________________________________________________________________________
TELEPHONE NO: (W)___________________ (H) __________________(Cell)_________________
EMAIL ADDRESS:_________________________________________

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Updated July 2020
 Ministry of Health & Wellness / Ministry of Education Youth
and Information School Health Programme
STUDENT’S MEDICAL REPORT

Part B: To be completed by a Physician or Family Nurse Practitioner and certified by the Physician

MEDICAL HISTORY

Please respond by putting a tick () under the appropriate column and record dates of last treatment and
remarks for positive responses.

Has your child ever been diagnosed or treated for any of the following conditions?
PAST HISTORY YES NO DATE(s) REMARKS
 Asthma/ Bronchitis ( ) ( ) ------------ -------------------------------
 Rheumatic Fever/Rh. Heart Disease ( ) ( ) ------------ ------------------------------------
 Congenital/other Heart Disease ( ) ( ) ------------ ------------------------------------
 Sickle Cell Disease ( ) ( ) ------------ ------------------------------------
 Seizures ( ) ( ) ------------ ------------------------------------
 Fainting spells/giddiness ( ) ( ) ------------ ------------------------------------
 Anaemia ( ) ( ) ------------ ------------------------------------
 Disorders of the Ears, Nose, Throat ( ) ( ) ------------ ------------------------------------
 Diabetes Mellitus ( ) ( ) ------------ ------------------------------------
 Hypertension ( ) ( ) ------------ ------------------------------------
 High Cholesterol ( ) ( ) ------------ ------------------------------------
 Arthritis ( ) ( ) ------------ ------------------------------------
 Recurrent headaches/Migraine ( ) ( ) ------------ ------------------------------------
 Visual or hearing disorders ( ) ( ) ------------ ------------------------------------
 Physical Disability ( ) ( ) ------------ ------------------------------------
 Psychological disorder ( ) ( ) ------------ ------------------------------------
(e.g. post- traumatic stress disorder)
 Infectious diseases ( ) ( ) ------------ -----------------------------------
 Allergies to: Penicillin/antibiotics ( ) ( ) ------------ -----------------------------------
 Any other substance ( ) ( ) ------------ -----------------------------------
 Any other condition ( ) ( ) ------------ -----------------------------------

Has your child ever been admitted to hospital or had surgery? YES NO
If yes, please explain for what reason & give dates. _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Is your child taking any medications? YES NO

If yes, please list (with frequency and duration). _________________________________________________

Menarche: YES NO N/A If yes, LMP:______________________________________

Has your daughter ever experienced dysmenorrhea? YES NO If yes, please state medication
prescribed for same: _______________________________________________________________________

EMOTIONAL HISTORY

Has your child ever been diagnosed with the following?

YES NO DATE(s) REMARKS
Depression ( ) ( ) ________ __________________________
Learning Disability ( ) ( ) ________ __________________________
Hyperactivity (ADHD) ( ) ( ) ________ __________________________
Behaviour disorder ( ) ( ) ________ __________________________
Anxiety ( ) ( ) ________ __________________________

Has your child experienced the following? YES NO

Recent stress e.g. death or relocation of a close family member, relative or friend ( ) ( )
Difficulty making friends, adjusting to new situations ( ) ( )
Difficulty concentrating in class ( ) ( )
History of fighting /hurting others ( ) ( )
Use of any of the following substances (alcohol, cannabis (ganja), cigarettes, ( ) ( )
Crack /cocaine, inhalants (e.g. sniffing glue), other)

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Updated July 2020
 Ministry of Health & Wellness / Ministry of Education Youth
and Information School Health Programme
STUDENT’S MEDICAL REPORT

Explain:______________________________________________________________________________
______________________________________________________________________________
FAMILY HISTORY

YES NO DATE(s) REMARKS

 Diabetes Mellitus ( ) ( ) ------------ -------------------------
 Hypertension ( ) ( ) ------------ -------------------------
 Heart Disease/Stroke ( ) ( ) ------------ -------------------------
 Sickle Cell Disease ( ) ( ) ------------ -------------------------
 Mental Illness ( ) ( ) ------------ -------------------------
 Cancer ( ) ( ) ------------ -------------------------
 Other, state ( ) ( ) ------------ -------------------------

MEDICAL EXAMINATION

Please give details of findings and verify immunization history

STUDENT’S NAME: ________________________________________________

HEIGHT: __________________cm WEIGHT: _______________kg. BMI (Kg/m2):________

(Calculate BMI: Eg. If, Wt. = 35 KG Ht. = 120 cm [1.20m] BMI = 35 ÷ [1.20mx 1.20m] = 24.3)

BMI-FOR-AGE (use chart for interpretation): ______________________________

WAIST CIRCUMFERENCE: ____________cm BP: ____________________

GENERAL APPEARANCE: ____________________________________________________________

NUTRITIONAL STATUS: __________________________ POSTURE: _____________________________

SKIN: _____________________________________TEETH/GUMS: _____________________________

HAIR/SCALP: ________________________________________________________________________

EYES: __________________________________ VISION: R L

(Indicate whether tested with glasses or not)

EARS: _________________________________HEARING: ___________________________________

NOSE/THROAT: ______________________________________________________________________

BREASTS: ___________________________________________________________________________

THYROID: ___________________________________________________________________________

RESPIRATORY SYSTEM: _____________________________________________________________

CARDIOVASCULAR SYSTEM: _________________________________________________________

ABDOMEN/GI SYSTEM: _______________________________________________________________

CENTRAL NERVOUS SYSTEM: ________________________________________________________

BONES AND JOINTS: _________________________________________________________________

GENITOURINARY SYSTEM: __________________________________________________________

DEFORMITIES/DISABILITIES: _________________________________________________________

URINALYSIS: PROTEIN: __________________________GLUCOSE: __________________________

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Updated July 2020
 Ministry of Health & Wellness / Ministry of Education Youth
and Information School Health Programme
STUDENT’S MEDICAL REPORT
BLOOD: _____________ LEUCOCYTES: _____________ OTHER: ______________

HAEMOGLOBIN (for all grade 7 students): __________________________________________

IMMUNIZATION HISTORY

Please indicate dates vaccines were received:

DATES ADMINISTERED
Vaccine 1st 2nd 3rd Booster 1 Booster 2 Booster 3
BCG
DPT/DT
Polio
MMR
Chicken Pox
Hep B
Hib
Pneumococcal
HPV
Other:
Other:
Other:
*Please provide a copy of the immunization card for the school records

OUTSTANDING DOSES?: YES NO

If Yes, specify: _____________________________________________________________________

ASSESSMENT

KEY FINDINGS: _________________________________________________________________________

________________________________________________________________________________________

REFERRAL/FOLLOW UP REQUIRED: YES NO

If Yes, specify: ___________________________________________________________________________

________________________________________________________________________________________

ADDITIONAL REMARKS & RECOMMENDATIONS: __________________________________________

________________________________________________________________________________________

PHYSICAL ACTIVITY: UNRESTRICTED AS TOLERATED LIMITED

If Limited, reason: _________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________

CERTIFIED FIT FOR ADMISSION TO SCHOOL: YES NO

______________________________________ _________________________________________
NURSE PRACTITIONER’S SIGNATURE ADDRESS

______________________________________ ________________ _________________

NURSE PRACTITIONER’S NAME (WRITTEN) NCJ REG. # DATE

(and/or)
_____________________________________ ________________________________________
DOCTOR’S SIGNATURE ADDRESS

_________________________________ ________________ ___________________

DOCTOR’S NAME (WRITTEN) MCJ REG. # DATE

(please affix stamp)

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Updated July 2020
 Ministry of Health & Wellness / Ministry of Education Youth
and Information School Health Programme
STUDENT’S MEDICAL REPORT
CONSENT TO MEDICAL TREATMENT

Dear Parent/ Legal Guardian,

While your child/ward is at …………………………….. ……………………………… it may

(Name of School)

become necessary to treat him/her for any health need/emergencies which may occur during school
hours. In cases of emergencies, attempts will be made to contact you urgently; however, for our
health professional/s to administer care to your child/ward, your consent is required.

Kindly complete the consent form below and return it with the remainder of the medical.

Thank you.

Yours sincerely,

………………………………………..
PRINCIPAL

Authorization.
To be completed by a parent or a legal guardian with the Nurse or Doctor

I………………………………………………………. hereby give/ do not give my consent for

(Name of Parent/ Legal Guardian)

health care/ treatment to be given to ------------------------------------------------------------------------------

(Name of Child)

in the event of any such need / emergency arising at ------------------------------------------------------

(Name of School)

SIGNATURE: ……………………………………… ………………………………………….

(Parent/ Legal Guardian ) Witnessed by, Nurse (RN) / Doctor

DATE: …………………………………………….. DATE: ……………………….……

MY CONTACT: ---------------------------------------------------------------------------------------------------

HOME ADDRESS: ------------------------------------------------------------------------------------------------

WORK ADDRESS: -----------------------------------------------------------------------------------------------

HOME PHONE NO: …………… WORK PHONE NO: …………… CELL NO.………………Email……………

OUR FAMILY DOCTOR IS:

NAME: --------------------------------------------------------------------------------------------------------------------------------

ADDRESS: -------------------------------------------------------------------------------------------------- --------------------------

TELEPHONE NO:-------------------------------------------------------------------------------------------------
NB. Nurses/Principals - this sheet must be copied and accompany the student to health facilities, when being taken
from school.
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