Hills Adventist College :: Medical Information Form

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13 December 2018

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Home > Parent Information > Medical Information Form

Medical Information Form

To be completed by Parents/Guardians on behalf of each child.

Information provided below will be treated with confidentiality. It will be used for the purpose of planning safe activities, or in the event of a medical situation arising at school or away on a trip.

Student Details

Full Name

Year level for 2019 *

Date of Birth *

Address

Parent Contact

Parent Name *

Home Phone

Work Phone

Mobile Number

Family Doctor

Name

Telephone

Health Cover Details

Medicare No

Do you have private health cover?

YesNo

If Yes, Membership No

If Yes, name of Health Fund

Emergency contacts below should be people OTHER than parents who may be contacted in the event that the College cannot reach a parent in an emergency situation.

Emergency Contact Details (other than parent)

Contact One

Relationship to child *

Full Name

Home Phone

Work Phone

Mobile Number

Contact Two

Relationship to child *

Full Name

Home Phone

Work Phone

Mobile Number

Contact Three

Relationship to child *

Full Name

Home Phone

Work Phone

Mobile Number

Date of last Tetanus Injection

Date of last Tetanus Injection - Unknown

Is your child currently taking any medication?

YesNo

Does your child have any condition or disability at present?

YesNo

If Yes, type and dosage

Has your child ever suffered from, or now suffers any of the disorders listed below?

Check the appropriate boxes

Rheumatic Fever Swollen or Painful Joints Heart Condition High Blood Pressure Abnormal shortness of breath Bronchitis or pneumonia Pleurisy or severe chest pains Asthma Hay fever Sinusitis Any other nose or throat trouble Ear infections/operations/problems Fainting, blackouts, fits or epilepsy Severe headaches or migraine Sleepwalking or frequent nightmares Bed Wetting Depression Claustrophobia Any other kind of mental illness Kidney or bladder condition Diabetes Severe loss of weight Hermia or rupture Any skin condition Any reaction to drugs or medicines Any other allergies (e.g. food, bee stings, etc) Unconsciousness Concussion or head injury Any major joint or back injury Any fractures Paralysis or muscular weakness Motion sickness

Any operations? Please specify

Any other illness or injury not mentioned already? Please specify

Please provide appropriate details if you have checked a box

Additional Medical Information

Blood Group

Allergies

Special Dietary Requirements

Allergy Details (if applicable)

Asthma Plan Provided

YesNo

Ventolin Provided

YesNo

Anaphylaxis Action Plan Provided

YesNo

Anaphylaxis Medication Provided

Allergic Reaction Action Plan Provided

YesNo

Allergic Reaction Medication Provided

YesNo

*

As parent/guardian I authorise the obtaining of any medical assistance, on my behalf if in the opinion of school staff or medical personnel such assistance is necessary, and agree to meet any costs incurred.

If you have letters or reports from specialists pertaining to your child's medical or academic needs, or a medical action plan please attach copies below.

Specialist Report 1Select File

:

Specialist Report 2Select File

:

Specialist Report 3Select File

:

Medical Action PlanSelect File

:

Parent/Guardian Name *

Contact Email Address *

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