Health Record Form

HEALTH RECORD FORM

GENERAL INFORMATION

• Date submitted *
• Pupil's full name *
• Parent to be contacted in case of emergency *
  MotherFather
• Mother's Name & Surname *
• Mother's Cell *e.g. 0117317400
• Other Number *e.g. 0117317400
• Father's Name & Surname *
• Father's Cell *e.g. 0117317400
• Other Number *e.g. 0117317400
• Alternative Contact Person *
• Relationship to pupil *
• Cell Number *e.g. 0117317400
• Medical Aid Name
• Medical Aid Number

PUPIL'S HEALTH INFORMATION

• Date of birth *
• Allergies
• Does Pupil suffer from a Chronic Diease? If yes, please contact the School Sister on medicalcentre@kingsmead.co.za *
  YesNo
• Has Pupil had surgery? *
  YesNo
• State what Chronic disease:
• State what surgery and when:
• Does Pupil have any Congenital Abnormalities that may impact on their health whilst at school? *
  YesNO
• Does the Pupil take daily / weekly medication? *
  YesNo
• If so, state what:
• If yes, state what medication is being taken:
• Any contagious diseases already contracted? *
  YesNo
• Is the Pupil's immunisation up to date? *
  YesNo
• Has the Pupil had their preschool and 12 year old booster vaccinations? *
  YesNo
• State when:
• If not, which immunisation vaccines were omitted?
• Any other medical information that Kingsmead should be made aware of:

LEGAL REQUIREMENTS:

• Should your child suffer from an allergy or chronic disease kindly request your own doctor to provide the information requested on the attached form ‘Administering emergency and chronic medicine’. No treatment in regard to allergies or chronic disease may be administered in the School or on tour without this consent from the Doctor (not the Parent).
• Name of General Practitioner: *
• Contact details of General Practitioner. *e.g. 0117317400
• Experience has shown that it is sometimes difficult to communicate rapidly with Parents or Guardians in an emergency. Please give our Medical Officer / Nursing Sister authority for immediate transportation by ambulance to the nearest casualty, in a case where it is found impossible, after repeated efforts, to get in touch with you. Please tick and initial whichever is applicable and delete which is not applicable.
• I agree to the above. *
  YesNo
• If NO, please advise (in a few lines) what to do in an emergency.
• I give permission for the School Sister to treat minor ailments and to administer medication. *
  YesNo
• Pupil's most recent vaccination record *Please use png/jpeg/pdf/doc
• Medical aid card *Please use png/jpeg/pdf/doc

 

Verification

• Please enter any two digits *Example: 12
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