HEALTH INFORMATION

HEALTH INFORMATION
Student's Name*
Date of Birth*

DayMonthYear
Date
NHI Number (if known)
Year Level*
This information will be used by the nurses and only shared with others who need to know, for example, the Ambulance Service, Emergency Department or Public Health Nurses. If this information is to be passed on you will be notified as soon as possible.

Name of person filling out this form:
Parent/Caregiver Name*
Phone Number*

Area CodePhone Number
Relationship to student*
If you are unsure about any of the questions or would like to discuss any of the following, please phone our Registered School Nurses, on 09 237 0195 DDI / 09 237 0117 ext 212.
DOCTOR/DENTIST
Which doctor/clinic does the student go to?
Ph
Which dentist does the student go to?
Ph
HEARING / VISION / SPEECH

Please describe any difficulty your student has with any of the following
Hearing
Vision
Speech
MEDICAL CONDITIONS
Asthma - do they have an inhaler?*

YesNoIf Yes, please provide name of medication
If yes, do they have an Asthma Action Plan

YesNo
Cardiac/heart problems - do they take medication?*

YesNoIf Yes, please provide name of medication
Diabetes (sugar in the blood) - do they take medication?*

YesNoIf Yes, please provide name of medication
Epilepsy (fits or seizures) do they take any medication?*

YesNoIf Yes, please provide name of medication
Migraines - do they take medicines*

YesNoIf Yes, please provide name of medication
Rheumatic Fever - do they take medicines or injections*

YesNoIf Yes, please provide name of medication
Are there any other medicines that you haven't already mentioned?*

YesNoIf Yes, please provide name of medication
Is there anything else you think we should know about?
ALLERGIES
Nuts - do they have an allergic reaction?*

SevereModerateMildNoIf Yes, what happens, describe the reaction
Bees - do they have an allergic reaction?*

SevereModerateMildNoIf Yes, what happens, describe the reaction
Medicines - do they have an allergic reaction?*

SevereModerateMildNoIf Yes, what happens, describe the reaction
Other - do they have an allergic reaction?*

SevereModerateMildNoIf Yes, what happens, describe the reaction
Have they ever been told that they need an epipen?*

YesNoIf Yes, have you supplies the school with the appropriate medication?
VACCINATION DETAILS
Is the student vaccinated for measles?*

YesNoIf Yes, please provide the date
Is the student vaccinated for tetanus?*

YesNoIf Yes, please provide the date
PERMISSION FOR GIVING MEDICATION AT SCHOOL
Sometimes it may be necessary for the nurse to consider giving students medication at school.

I give permission for the School Nurse to give:
Paracetamol (eg Panadol)

YesNo
Ibuprofen (eg Nurofen)

YesNo
Antihistamine

YesNo
(student's name)
this medicine if they have examined them and believe that it would help.
Parent/Guardian Signature

Clear
Please print your name
Email
example@example.com
NOTE

In case of a serious illness or accident students will be taken to a doctor for care. An ambulance may be called if necessary. Please ensure that the school has your most current contact details so that a parent/caregiver/emergency contact may be called. If you are unsure about any of the questions or would like to discuss any of the following please contact one of our Registered School Nurses 09 237 0195.
Should be Empty:

HEALTH INFORMATION

DOCTOR/DENTIST

HEARING / VISION / SPEECH

MEDICAL CONDITIONS

ALLERGIES

VACCINATION DETAILS

PERMISSION FOR GIVING MEDICATION AT SCHOOL