ISA Student Health Form

Student Health Form
Welcome to the International School of Amsterdam.

The ISA Nurse's Office provides your child with general health care during the school day. To provide this care we require current information about your child's health.

Therefore, we ask you to read carefully and complete this Student Health form at least two weeks before your child's first day of school.

Privacy Note: This information is necessary so that your child may be enrolled as a student at ISA. Our lawful basis for processing this information is Contractual. For further information please see our Tier 2 Privacy Notice.

All student medical information provided will be input into the school digital files. The digital files are well secured and only staff directly involved have access. All paper files will be stored confidentially in your child’s file in the Nurse’s Office.

The medical information (such as allergies, ADHD, asthma, diabetes) will be shared with the teachers, youth health doctor from GGD (Children's Public Health Service) and selected support staff.

* If you disagree with sharing any information regarding your child, please contact the Nurse’s Office.

Student and Family Details
Student name*

First NameLast Name
Student birth date*

DayMonthYear
Date
gender
FemaleMaleOther
Grade level
Parent 1 name*

First NameLast Name
Parent 1 email*
Parent 1 mobile number

country codephone number
Parent 1 home or office number

country codephone number
Parent 2 name

First NameLast Name
Parent 2 email
example@example.com
Parent 2 mobile number

country codephone number
Parent 2 home or office number

country codephone number
Netherlands home address (if available)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact (in case both parents are not available)

First NameLast Name
Emergency contact relationship to family
Emergency contact phone number

Country CodePhone Number

Medical Information and Health History

Please answer all questions, indicating N/A if not applicable
Allergies
Does your child have any known any severe allergies?*
If yes,→ Please specify what your child is allergic to: (open box)
Does your child have any known allergies to bee stings, pollen, dust, animals or other?*
If yes, specify which allergen and list reactions/symptoms and treatments
Does your child have any food allergies or diet restrictions?*
If yes, list which foods, reactions/symptoms and treatment
Does your child have any other allergies?
If yes, list reactions/ symptoms and treatment
Does your child have a history of severe allergy or anaphylactic reaction? Has Adrenaline or Epinephrine ever been prescribed?*
Please list dosage
If yes, please provide two (2) Adrenaline/ Epinephrine auto-injectors for your child.

Has your child ever required treatment for any of the following conditions?
Asthma*
Please give further details - Has your child ever been hospitalised due to asthma? What inhalers are prescribed? How often does your child use their relief inhaler?
Diabetes*
List whether Type 1 or 2 and current treatment regime.
Seizures / epilepsy*
List date of last seizure and any treatment
Heart condition*
Specify type of condition, symptoms and treatment
Bleeding or endocrine disorders
Specify type of condition, symptoms and treatment
Migraine/frequent headaches*
List symptoms and treatment
Eczema/skin condition*
Specify type of condition, symptoms and treatment
Hearing problems/ frequent ear infections*
Describe difficulties, symptoms and treatment. If relevant: when was the last check-up?
Vision problems*
Indicate whether your child wears glasses/contact lenses, is colour blind or has other vision issues.
Menstrual problems (if applicable)*
Symptoms and treatment
Has your child previously had an injury, serious surgery, long hospitalization or other health condition, which could affect school participation?*
If yes, explain and indicate whether treatment is still required
Any other health conditions
If yes, explain
Any motor development difficulties?*
Has any physiotherapy treatment been required?
What is your child's height (in cm)?*
What is your child's weight (in kg)?*
YesNo

Medications
Does your child take prescribed medication, including any inhalers, on a regular basis?*
List medication, purpose and dosage.
For the safety of all students, no student may carry any medication on campus (outlined in ISA School Handbook).

Occasional exceptions may be made: please contact the School Nurse. Students may have access at all times to their medication, such as inhalers, from the Nurse's Office.

If your child is prescribed any medication that he/she may require during school hours, please fill in the linked Permission form for Medication and bring the medication/s to the ISA Nurse's Office no later than the first day of school.

The Nurse's Office maintains a stock of over-the-counter medication and students are welcome to visit the Nurse's Office if they require any of these medications during the school day and parental consent has been given.

Emotional/ Development/ Behavioral / Mental Health issues
Does your child have language or speech development issues?*
If yes, please specify
Has your child been diagnosed with ADD, ADHD or ASD?*
If yes, please specify. This information will be visible on the school database. If you disagree with this, contact the Nurse's Office.
Has your child had a significant life event that continues to affect their life?*
If yes, please specify
Does your child have a past history of, or is currently affected by, anxiety, depression or panic attacks?*
If yes, please specify

Submission Checklist

Please submit this form and send the following additional documents to nurse@isa.nl
- a copy of immunisation records
If necessary, complete the Permission for Medication form.
If you have a copy of the immunisation records you can upload them here. Otherwise you should email a copy to nurse@isa.nl

Browse Files

Cancelof
If you have a copy of the Doctor's Assessment Form, signed by your home doctor/paediatrician, you can upload it here. Otherwise you should email a copy to nurse@isa.nl

Browse Files

Cancelof
The ISA Nurse will meet with parents/guardians of students with medical conditions.
YesNo
Parent/Guardian Signature

I hereby declare that all the information provided in this form is complete and correct to the best of my knowledge.

I acknowledge that it is my responsibility to inform the ISA Nurse's Office of any changes in my child's health, physical condition or medical needs.

I understand that entering my name in the parent/guardian field below constitutes my legal signature and serves as confirmation that the information on this form is correct including all authorisations given.
Parent/guardian signature*
Type your name
Today's Date:

DayMonthYear
Date
Should be Empty:

Student Health Form

Student and Family Details

Medical Information and Health History