Seoul International School

AUTHORIZATION FOR MEDICAL PROCEDURE

NAME OF STUDENT: D.O.B.: HOMEROOM/GRADE:

PART 1: PARENT/GUARDIAN AUTHORIZATION

I request medication(s) be given during school hours as ordered by my child’s physician. I also request the medication(s) be given to the field trips, as prescribed.
I will notify the school of any change in the medication(s).
I give permission for the medications to be given by the school personnel as delegated, trained, and supervised by the school nurse.
I give permission for the school nurse to communicate, as needed, with school staff about my child’s medical conditions(s) and the treatment prescribed.
I give permission to S.I.S. to release appropriate medical information to the hospital in case of emergency.

PART 2: EMERGENCY CARE PERMISSION

Permission is hereby given for emergency measures to be taken in case of accident or sudden illness with the understating that I will be notified as soon as possible.
I acknowledge that it is my responsibility to inform Seoul International School Health Office of any changes in my child’s health, physical condition, or medical needs

PARENT/GUARDIAN SIGNATURE: Date:

 Seoul International School
STUDENT MEDICAL HISTORY & HEALTH FORM

TO BE COMPLETED BY THE PARENT OR GUARDIAN:

STUDENT INFORMATION
STUDENT’S NAME (Last, First): DATE OF BIRTH (MM/DD/YYYY): BLOOD TYPE: SEX: HOMEROOM (GRADE):
Male ( ) Female ( )
Father’s Name (Last, First): Cell #: Mother’s Name (Last, First): Cell #:

Home Address: Home Phone #: Email Address:

Emergency Contact (Other than parents):

Name: (Relation: ) Contact number:
PAST OR PRESENT MEDICAL HISTORY
Does the child/student have a past or present medical history of the following?
ADD/ADHD Y N Epilepsy/Seizure Disorder Y N Hearing Problems Y N Skin Problems Y N
Anxiety Disorder Y N Frequent Headaches Y N Heart Disorder Y N Speech Difficulty Y N
Chicken Pox Y N Frequent Nosebleeds Y N Hepatitis A/B/C Y N Vision Problems Y N
Diabetes  Y  N Gastrointestinal Disorder Y N Scoliosis Y N Others: Y N
If you have checked on any of the above medical history, please explain in detail:

Does your child have allergies?  Y  N

If YES, student is allergic to:
Reactions the student may have:
Treatments the student may need after exposure:
Does your child have asthma? Y N
If YES, does the student need an inhaler?  Y  N Y N
If the student needs an inhaler, please indicate if the inhaler will:  remain with the student or  be provided to the Health Office for emergency use.
If your child have other significant health conditions that may require emergency medical care at school, child care, field trip or sports activity, please explain in detail:
 Seoul International School
STUDENT MEDICAL HISTORY & HEALTH FORM

TO BE COMPLETED BY THE PARENT OR GUARDIAN:

STUDENT INFORMATION
STUDENT’S NAME (Last, First): DATE OF BIRTH (MM/DD/YYYY): BLOOD TYPE: SEX: HOMEROOM (GRADE):
Male ( ) Female
CURRENT MEDICATION STATUS
Medication Permission: Please check the following list of common medications which Health Office may administer to your child as needed at school
Acetaminophen (Tylenol) - pain and fever relief Y N Hexamedine/Tantum spray for sore throat Y N
Ibuprofen (Advil) - pain relief and anti-inflammatory Y N Cegaton Troche - For sore throat, stomatitis Y N
Zyrtec (tablet) - for allergy (Nasal/Sinus Congestion) Y N Festal — for stomach indigestion Y N
Please list any medication the student takes on a regular basis:

IMMUNIZATION RECORD (DATES: MM/DD/YYYY)

DT aP OPV / IPV MMR Chicken pox TB Skin Test/Result Tdap HepB
1. 1. 1. 1. 1.
2. 2, 2. 2. 2.
3. 3. 3.
4. 4.
5.
IMMUNIZATION GUIDE AND REQUIREMENTS Students who have lost records, must have one OPV booster,
2 mo 4 mo 6 mo 15 mo 18 mo
4-6 yr 11-18 yr one DTaP *(if under 6 years of age) or Td (if under 18 years of
age) booster, and one MMR booster along with annual TB Skin
DTap/Td #1 #2 #3 #4 #5 Td/Tdap
test. Complete record with appropriate immunizations.
OPV/IPV #1 #2 #3 #4
MMR #1 #2 *It is parental responsibility to update medical records.
Chicken pox #1 #2
T.B. Skin All students enrolled at Seoul International School are required to have PPD skin test (Pease read page 1-3 and then sign) Signature / date
Test/Result OR chest X-ray every 2 years.
 PHYSICIAN’S EXAMINATION
(MEDICAL EXAM MUST BE CURRENT – WITHIN 12 MONTHS OF ENTRY DATE)

Required tests Date (MM/DD/YY) Result

Name (Last, First) Grade Date of Birth (MM/DD/YY)
TUBERCULIN SKIN TEST
or Chest X-ray
Sibling at SIS (name/grade)
HEMOGLOBIN
URINALYSIS
Height cm Weight Kg Pulse
(If TB skin test result is positive, chest X-ray is required regardless of previous BCG
Vision R: L: Both vaccination.)
Blood Pressure / Corrective Lens □ YES / □ NO
(Blood Pressure only for students age 11 and older) SIS requires evidence of immunization for the following (MM/DD/YY):
I have seen evidence that these have been administered.
(O) Normal (X) Abnormal (Comment : Specify consultation requested) YES NO
Ears/Hearing Musculoskeletal
DT&P #1 OPV/IPV #1 MMR #1
Nose Spine
#2 #2 #2
Mouth Skin
#3 #3 HepB #1
Throat Neurological
#4 #4 #2
Neck Nutritional
#5 #3
Heart Emotional / Psychological
Varicella #1 Td/ 11-12 years
Lungs Behavior
#2 Tdap #1
Abdomen Speech
Physician’s Comments : * Please print the exact date (MM/DD/YY) of vaccinations received.

NOTE TO THE PHYSICIAN : Please be strict on immunization. Students who

have lost records must have the OPV booster, one DTap or Td (if between ages
Please list any medication the student takes on a regular basis. 11 and 18) booster, and one MMR booster along with the annual Tuberculin Skin
Note : A separate medical form is required for all medication and treatment to Test. Please administer appropriate immunization for incomplete records.
be administered at school. Thank you.
Name of Medication Purpose Dose/Times

Physician’s Name Signature

This student is physically able to participate in all physical education and sports
activities : □ YES / □ NO
Hospital Date
If NO, Please explain :