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School Medical Form

This medical form collects information about a student, including their name, date of birth, emergency contacts, health issues, immunization status, medications, and permission for emergency medical treatment. The form asks the parent or guardian to note any health problems, physical limitations, or behaviors that could impact participation in science class. It also inquires about the student's immunization records and whether they are prone to conditions like asthma, headaches, or allergies. At the end, the parent must sign giving the school permission to provide medical treatment in case of emergency.

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Kendy Salvador
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75 views

School Medical Form

This medical form collects information about a student, including their name, date of birth, emergency contacts, health issues, immunization status, medications, and permission for emergency medical treatment. The form asks the parent or guardian to note any health problems, physical limitations, or behaviors that could impact participation in science class. It also inquires about the student's immunization records and whether they are prone to conditions like asthma, headaches, or allergies. At the end, the parent must sign giving the school permission to provide medical treatment in case of emergency.

Uploaded by

Kendy Salvador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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School Medical Form

NAME OF STUDENT ______________________________ DATE OF BIRTH ___________________


NAME OF PARENT/GUARDIAN__________________________________ HOME PHONE _____________________
WORK PHONE ____________________
IN CASE OF EMERGENCY CONTACT PARENTS FAMILY DOCTOR __________________
/OR ____________________________PHONE _________________ OFFICE PHONE ___________________
Medical Insurance Plan No.:
__________________________________

A. Please note any health problem, physical handicap, emotional difficulty, behavioural problem, or
facts
which may limit full participation in the science classroom.
___________________________________________________________________________________________
B. Student’s immunization shots are current , i.e. tetanus and diphtheria, typhoid, smallpox, and polio
vaccine
YES (__) NO (__)
C. Student is subject to:

__ __ sensitive skin __ __
asthma __ sinus sleepwalking nosebleed
trouble
__ ear __ convulsions __ high blood
ache __ frequent __ pressure
colds headache
__ fainting __ motion sickness
__ tonsillitis __ __ kidney problem __ allergies (describe)
__ eye infection bronchitis

D. Medications: I would like my child to be given,


Name of Medication(s) _______________________________________
Purpose of Medication _______________________________________

******************************************************************
In case of emergency, I hereby give permission to the physician selected by the school to provide
necessary treatment for my child.

Parent/Guardian signature: _________________________________________ Date: _______________________

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