Medical Information & Consent Form Student Details

Medical Information & Consent Form
Student Details
NAME___________________________________
YEAR LEVEL_______
Gender: M/F
Height_____________ Weight ______________
Date of birth: _______________
Religion: ___________________
Medicare Number: ___________________ Exp Date: ____________ Position: ________
Private Health Fund: ___________________________
PARENT CONTACT DETAILS
Name: ______________________________ Relationship to student: _____________________
Ph: (H) __________________ (W) ___________________ Mobile: _______________
Address: ____________________________________________________________________
_____________________________________________________________________
IMMUNISATION RECORD
Year of last Tetanus or ADT or DtPA booster: ______ Year of last Polio booster: ________
Year of last Measles/Mumps/Rubella: ______Year of Chicken Pox Vaccine: ________
Year of last Hepatitis B vaccination: ______Year of Meningococcal Vaccine: ________
Other: ______________________________________________________________________
MEDICAL HISTORY
Does your son or daughter suffer from any of the following:
Asthma Diabetes: Epilepsy: Heart Problems:
Neck/Back Condition: Mental/Emotional Illness Travel Sickness
Other: (please specify and attach any relevant information)
_______________________________________________________________________________________
_______________________________________________________________________________________
PTO:
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Medical History & Consent Form (continued)
OTHER HEALTH ISSUES THE SCHOOL SHOULD BE AWARE OF:
e.g. Hepatitis B carrier, bed wetter, psychological problems, special needs/disability, hearing or sight
problems, any recent operations or injuries (give details and approximate dates):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
ALLERGIES
Please complete this section if your son/daughter has any allergies. These may include foods, other
additives, medications, insect bites, plants or pollens, detergents, cleaning agents or others.
1) What is the student allergic to ___________________________________________________________
2) What are the signs and symptoms of the allergic reaction _____________________________________
_______________________________________________________________________________________
3) Has the student at any time in the past suffered from:
Localised Reaction (any rash, itching, swelling at the site the toxin has entered)
Systemic Reaction (any rash, itching ,swelling away from the site where the toxin has entered)
Anaphylactic Reaction (severe breathing problems, swelling of the body, emergency situation)
Please have your doctor complete an anaphylaxis management plan.
4) What medication does the student take to prevent an allergic reaction
5) What treatment plan is followed for the student if an allergic reaction occurs _____________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PRESCRIPTION MEDICATIONS/CURRENT TREATMENTS
List prescription medications, their dose and frequency that your son/daughter is currently taking AND
any current treatment(s) the College should be aware of:
_______________________________________________________________________________________
_______________________________________________________________________________________
CONSENT TO ADMINISTER FIRST AID AND OR MEDICAL ATTENTION
I/we give permission to a teacher/staff member to administer First Aid to my child in the event of injury or
illness.
I/we authorise a teacher/staff member to obtain medical attention for my child at his/her discretion in the
event of such injury or illness.
I/we agree to pay for such medical expenses or pharmaceutical supplies that, on medical advice, may be
incurred.
Signed ……………………………………………………………….. Date…………………………………
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