DHA MEDICAL FORM

Medical Form

The parent of legal guardian of the student should fill this form. He or she is responsible for the below- mentioned information. Medical report about the health problem should be attached. Parents and Legal Guardians are responsible for informing school nurse about any change that occur in health status of the student. They should provide the school nurse with the required reports needed to be added the student health file. Please attach medical reports about the Student’s health problem, if any
Student Name*

First NameLast Name
Year and Class*
EID*
In case of Emergency and not being able to reach parents, the following person can be contacted: *
Please add name and mobile number and relationship to the student
Medical history of student ( Please tick if yes) and specify in others*

Any allergy to drug, food, dust …..Cardiovascular problemDiabetesHypertensionAsthmaRenal problemEpilepsy seizures/ convulsion seizuresEpistaxisHemolytic Anemia, type G6PDHereditary Blood Disease(e. g. Thalassemia, sickle cell anemia, Hemophilia), Please specify if anySkin problemHearing problemEye problem(Myopia, Hyperopia, ….), Please specify if anyAny case that may weaken Immunity System such as Cancer (Blood cancer, Lymphoma), or transplantation, Please specify if anyOne of the following diseases: (Mumps, Measles, Diphtheria, Pertussis, Chickenpox, Tuberculosis), Please specify if anyViral hepatitisPoliomyelitis (Infantile paralysis infection)Mental of Behavioral Problem, Please specify if anyIs there a previous exposure to any accident?Is there any previous hospitalization? Please mention the cause if anyIs there any previous exposure to surgery? Please mention the cause if any?Is there any previous blood, antibodies or plasma transfusion?Was there a need to use any medical aid device? Please specify if anyNo medical diseasesOther
Drugs or Treatments taken continuously ( include name and dosage)
Specific Instructions of the treating doctor regarding Nutrition
Specific Instructions of the treating doctor regarding exercise and physical activity
Specific Instructions of the treating doctor to school nurse to be applied during the school day
Family history*

HypertensionDiabetesTuberculosisMental disorderStrokeNo family history of diseasesOther
I agree for my child to have curative and/or preventive services that may include first aid, screening for height, weight, vision acuity, hearing test, dental checkup, Comprehensive Medical Examination, referral to emergency room when necessary, administer emergency medications when needed, and applying the Healthcare Management plan which is planned for based on the instructions of the treating doctor and parents. Parent/ Guardian approval and verification for the above mentioned information

I certify that the above provided information are validI agree for my child to be provided with the above mentioned health services according to the needI disagree for my child to be provided with the above mentioned health services (In case of refusal, the above services will not to be offered except in emergency situations which require immediate intervention)
Name of parent or legal guardian*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Medical Form