MEDICAL INFORMATIONPlease add any relevent medical information for your child. 1. STUDENT INFORMATION Last Name First Name 2. MEDICATION PERMISSION Paracetamol (Tylenol etc) Paracetamol may be administered to your child by the school nurse with your permission. Please complete below if you agree. 2.1 Has your child taken paracetamol in the past? YESNO 2.2 Was there any adverse allergic reaction to paracetomol? YESNO 2.3 I give permission for my child to be given paracetamol (recommended dose for weight and age) YESNO Ibuprofen (Eve etc) Ibuprofen may be administered to your child by the school nurse with your permission. Please complete below if you agree. 2.3 Has your child taken ibuprofen in the past? YESNO 2.4 Was there any adverse allergic reaction to ibuprofen? YESNO 2.5 I give permission for my child to be given ibuprofen (recommended dose for weight and age) YESNO Personal Medications 2.6 I give the school nurse or authorised personnel permission to administer medication as prescribed by their physician. I will send the medication in the bottle properly labeled with their name and instructions. YESNO 2.7 If you selected yes to the above, please provide details of medication/treatment and upload any relevant documentation. Medication 1 Name Medication 1 Expiration Date Medication 1 Dose Medication 1 Time Period Medication 1 Should Remain At School? YESNO Medication 1 Is Picked Up And Self Administered By Child? YESNO Medication 1 Should Remain Refrigerated? YESNO Medication 1 Other Notes -- Medication 2 Name Medication 2 Expiration Date Medication 2 Dose Medication 2 Time Period Medication 2 Should Remain At School? YESNO Medication 2 Is Picked Up And Self Administered By Child? YESNO Medication 2 Should Remain Refrigerated? YESNO Medication 2 Other Notes 3. MEDICAL HISTORY Do you have any medical history or concerns in the following areas? 3.1 Pre/post natal concerns YESNO 3.2 Vision concerns YESNO 3.3 Hearing concerns YESNO 3.4 Head injury YESNO 3.5 Autism/ASD YESNO If you selected yes to any of the above, please provide details of medication/treatment: Has your child ever suffered from any of the following? 3.6 Asthma YESNO 3.7 Allergies YESNO 3.8 Heart Condition YESNO 3.9 Fears/Phobias YESNO 3.10 Diabetes YESNO 3.11 Epilepsy YESNO 3.12 Muscular / Skeletal / Ankle / Back / Knee / Joint Problems YESNO 3.13 Past Injuries / Operations YESNO 3.14 Headaches YESNO 3.15 Nosebleeds YESNO 3.16 Other Medical Conditions YESNO 3.17 Is Your Child Currently On Any Medications YESNO If you selected yes to any of the above, please provide details of medication/treatment and upload any relevant documentation. File Type: jpg,jpeg,png,pdf,doc,docx,pages / File Size: ~5MB 4. IMMUNISATION 4.1 Is your child fully immunised for their age according to the Japan / home country requirements? YESNO If you selected no, please provide any relevant details. 5. SPECIALIST ASSESSMENTS 5.1 Audiology Clinic YESNO 5.2 Child Guidance YESNO 5.3 Occupational Therapist YESNO 5.4 Psychiatrist / Psychologist YESNO 5.5 Specialist Clinic YESNO 5.6 Speech Pathologist YESNO 5.7 Other YESNO If you selected yes to any of the above, please provide details of medication/treatment and upload any relevant documentation. File Type: jpg,jpeg,png,pdf,doc,docx,pages / File Size: ~5MB 6. ADDITIONAL MEDICAL INFORMATION 6.1 Does he/she have any other medical condition or physical/emotional/behavioural disability? YESNO 7. PHYSICAL EDUCATION 7.1 Does the applicant have any physical impairment that may affect his/her involvement in physical education or sport? YESNO 8. EMERGENCY PROCEDURES AND TERMS & CONDITIONS 8.1 Notifiable Conditions The school should be notified if your child contracts any infectious disease or infectious condition. Examples of these diseases or conditions include: measles, mumps, chicken pox, glandular fever, rubella, hepatitis a & b, is HIV positive, or has been diagnosed with AIDS. Parents are encouraged to inform the school of any other condition the child may have, or assistance they may require. The above information is required as a public safety measure and for use in emergencies on a need-to-know basis. This information will be treated as confidential. The school considers that is it absolutely essential that it has complete knowledge of each student's medical condition and history in so far as it might affect other students, school staff or members of the public. For this reason, full medical disclosure is a condition of enrolment at the school, and failure to make full disclosure is deemed to be reasonable cause for cancellation of enrolment of the student. I Agree 8.2 Emergency If your child is unwell or injured during school hours, they will be cared for in the school clinic and you will be notified if you are required to collect them from the school. In case of an emergency at the sdchool, every effort will be made to contact parent(s). For this reason, it is your responsibility to ensure that your correct address and phone number is on record at the office. Should the school be unable to contact you, an ambulance will be called. I Agree 8.3 Permission In Case Of Emergency I give permission for the principal or nominated staff to act on my behalf, to choose a registered medical practitioner, and treatment as deemed necessary by the registered medical practitioner. I also accept that an ambulance may be used. All students are covered by the school's insurance (terms and conditions apply). The cost of an ambulance is covered for Japanese residents, otherwise by your own medical insurance. I Agree 9. PARENT INFORMATION 9.1 Submitted By I confirm that all information given above is true and complete
