PHOTO
Medical History
Full Name
Nickname
Date of Birth
PIN
Entry Year
Entry Date
Mother’s Name
Father’s Name
Mother’s mobile phone
Father’s mobile phone
Home phone
Home address
Mother’s office & phone
Father’s office & phone
Contact person when parents cannot be
reached
Name
Lives with
Phone
Weight
Height
Sight
Hearing
Blood group
Significant history
Drug allergies
Food allergies
Other allergies
Special health problems
Family history of medical, learning, physical
or mental health issues
Behavioural problems at home
Eats breakfast?
Wake up time
Sleep time
Medical conditions: Please tick as appropriate
Accident
Asthma
Congenital anomalies
Convulsions / epilepsy
Diabetes
Encephalitis
Heart condition
Internal parasites
Liver disease
Lung disease
Malaria
Measles
Mumps
Renal disease
Rubella
Skin disease
Surgery
Thyroid
X Ray
Other
Details and comments
Vaccinations (please tick):
TB
Hepatitis B
DPT
Polio
HIB
Rota Virus
MMR
Influenza
JE
Chicken pox
IPD
Hepatitis A
Typhoid
Rabies
Other
Details and comments
Prenatal and birth information (please tick):
Normal birth
Forceps Vaccuum
C section with indication
Full term
Premature
Head presentation, transverse
or breach
Developmental milestone
Age
Consultation
Sitting unaided
Speech pathologist
Crawling
Audiologist
Walking
Psychologist
Toilet trained during day
Neurologist
Toilet trained at night
Occupational therapist
First word spoken
Pediatrician
2-3 word sentence spoken
Other
Current medical problems
Current medication
Date
I give my permission for emergency measures to be initiated in case of accident or
sudden illness with the understanding that I will be notified. I certify that all information
on this record is complete and accurate.
Parent/guardian signature
Date
I give my permission for the school nurse to administer the following medicines when
necessary.
Parent/guardian signature
Date
Please tick as appropriate
Tempra Forte syrup for pain or fever
Nurofen suspension for temperature 38.5°C or above
Dimetapp Elixir for common cold
Felex syrup for cough with secretion
Atarax syrup for allergic skin rash
Mybacin lozenges for sore throat
Electrolyte drink for dehydration
Motilium suspension for nausea and vomiting
Alum milk for stomach ache
M-Salol for tummy ache or mild diarrhea
Air-X chewable tablet for excess gas in tummy
Ospar eye lotion for eye rinse
Hista-oph eye drops for eye allergy
Solcoseryl oral paste for oral lesion or teething pain
Recorded with school nurse
Nurse’s signature:
Remark
Date