New Student Health Form

This form must be filled out completely. Any changes or updates to your child's health information should be immediately communicated to the School Nurse.
Student Information
NAME
First Name
Middle Name (if present)
Last Name
Nickname / Preferred Name
Grade
PERSONAL INFORMATION
Gender

MaleFemale
Date of Birth

DayMonthYear
Address
PARENT INFORMATION
Father's Name
Country Code
For example (Thailand +66)
Phone Number
Please follow your local phone number format.
Mother's Name
Country Code
For example (Thailand +66)
Phone Number
Please follow your local phone number format.
Student Lives With
Student's Blood Type
Food Restrictions
ALTERNATE PERSON(S) TO CONTACT IN CASE OF EMERGENCY
Person Name 1
Relationship to Student 1
Country Code
For example (Thailand +66)
Phone Number 1
Please follow your local phone number format.
Person Name 2
Relationship to Student 2
Country Code
For example (Thailand +66)
Phone Number 2
Please follow your local phone number format.
HEALTH CONCERNS
Does your child have any allergies (to medication, food, pets, etc.)?

YesNo
If yes, provide details
Does your child have an illness or condition (heart condition, seizure, etc.)?

YesNo
If yes, please submit medical certificate
Does your child have a suspected or diagnosed special need (ADD/ADHD, Autism, speech delay, etc.)?

YesNo
If yes, please submit medical certificate
Has your child received any psychological counseling or visited a psychologist/psychiatrist?

YesNo
If yes, please submit professional evaluation
Has your child ever had a serious illness, accident, or operation?

YesNo
If yes, provide details
Is there any health concerns for which your child is or has been receiving treatment?

YesNo
If yes, provide details
Do any of above prevent participation in Physical Education?

YesNo
If yes, please submit physician's confirmation
MEDICATION
Is the student on medication

YesNo
If yes, please list the medication(s) (Drug name, dosage, timing)
If your child develops fever or pain, he/she can be given

Paracetamol (Tylenol/Tempra)Nothing
Please attach a photocopy of your child's immunization record to this form. If there is any other information not covered on this form that you feel important for us to know, please note here.
Signature

Clear
Parent/Guardian's Printed Name
Date Filled Out/Submitted

DayMonthYear
Should be Empty:

NAME

PERSONAL INFORMATION

PARENT INFORMATION

ALTERNATE PERSON(S) TO CONTACT IN CASE OF EMERGENCY

HEALTH CONCERNS

MEDICATION