Braeburn School Arusha

Braeburn School Arusha

Medical Information Form

The Nurse’s Room provides First Aid services during school hours, after school up to 5 pm and at school functions for all students, staff and visitors on campus. It is therefore, essential that the school has up to date information about your child’s health and medical requirements. Please complete and return this form as soon as possible to the school secretary.

Name of the Student: ______Year: ______

Date of birth: ______Date of submission of this form: ______

Brothers/sisters in the school: ______Year: ______

______Year: ______

______Year: ______

Medical Insurance Card (type and number): ______

Name of Parent/Guardian: ______

Parent/Guardian contact number: Home: ______

Office: ______

Mobile: ______

Another Useful Contact: Name: ______No.:______

In case of emergency please contact: ______

Child’s Doctor: ______Hospital/Clinic office no: ______

Doctor’s mobile: ______

Please indicate all immunisations given, with the approximate date:

Immunisation / Date/ year immunised
Polio
DPT
MMR
Tetanus
HIB
Meningitis
Havrix D
Hep B
Yellow fever
BCG
Other – please specify:

Please indicate any infectious diseases suffered by your child by filling the approximate date/year.

Illness / Date/ year suffered
Chicken pox
Measles
Rubella
Whooping cough
Mumps
Other (please specify)

Please tick any of the following from which your child suffers:

Eczema ( ) Asthma ( ) Sinusitis ( ) Hay Fever ( ) Diabetes ( ) Heart Conditions ( ) Epilepsy ( ) Migraine ( ) Sickle cell trait ( ) Eating disorder ( )

Others – please specify: ______

Does your child experience any physical, emotional or cognitive difficulties? If so, please give details: ______

______

Please give details of any personal medication your child carries to school eg. inhalers, insulin, Ritalin:

______

______

Allergies

Please give details of all allergies (eg. food, medicines, antibiotics, nuts, bee stings etc).

______

______

Please give below any hospitalisation and operations that your child has undergone:

______

Medicine Administered at School:

Tick to indicate that you give permission for any of the following to be administered to your child at school, by the school nurse:

Paracetamol preparations: Calpol / Panadol( ) Promethazine( ) Buscopan( ) Eno( ) Polycid/Actal( ) Flu cold caps( ) O.R.S (salts)( ) Ponstan( ) Cough syrup( ) Ventolin( ) Glucose( ) Lozenges( ) Brufen( ) Piriton( )

For external use only: Visine Eye drop( ) Betadine( ) Deep Heat( ) Deep Freeze( ) Burn cure( ) Spirit( ) Savlon/Dettol( ) N/Saline( ) Anthisan cream( )

Please give details of any other information concerning your child’s past or present medical and/or dietary history: ______

If you cannot be contacted in case of emergencies, do we have your consent to transport your child or use ambulance services to transport your child to a hospital? YES /NO

If yes, please indicate your preference: Selian ( ) Ithna Asheri ( ) AAR ( ) Aga Khan ( ) AICC ( ) Total Care ( ) Other - please specify:

______

Is there any reason why your child is unable to participate fully in all school sports and activities on and off campus?

Yes ( ) No ( )

If 'Yes', please specify the particular activity that cannot be undertaken and the reason why.

______

______

Full Name: ______Signature of Parent/Legal Guardian:______

Date: ______

PLEASE ADVISE THE SCHOOL OFFICE IN WRITING OF ANY CHANGES TO THIS INFORMATION.