Microsoft word - gsis_medical_form revised summer 08.doc
Gyeonggi Suwon International School Entrance Health Form
Student’s Name (Last , First Name)
Father’s or Legal Guardian’s Name:
Mother’s or Legal Guardian’s Name:
Permission for Giving Medication for Minor Complaints
I give permission for my child to be given medicine at the nurses discretion.
Tylenol (for minor aches, menstural cramps, and headache)
Pepto Bismol (for nausea, diarrhea, stomach ache, and heartburn)
In the event that I cannot be reached in an emergency, I give permission for my child to receive medical treatment, including transport to the most accessible
hospital, as deemed necessary by school authorities.
Student’s Name: _________________________________________ Date of Birth: ____________________________ Sex: Male ( ) Female ( )
Your accurate and thorough answers help us to better serve your child.
To the best of your knowledge, has your child had any problems with following? Please check yes or no.
Comments if “Yes”
Comments if “Yes”
* Describe any serious illness, surgery, injuries, or hospitalizations: ________________________________________________________________
* Does any condition affect or limit your child’s full participation in physical education classes, sports, or school trips? Yes ( )No( )
If yes, please explain __________________________________________________________________________________________________________
* Check here if you want to discuss confidential information with school nurse or other school authority: Yes( ) No( )
Student’s Name: ______________________________________ Date of Birth: ___________________________ Sex: Male ( ) Female ( )
Record complete dates (yyyy/mm/dd) of vaccine dose given
TB Screening (to be completed by a school nurse)
List all prescription and over-the-counter medications your child takes regularly:
Does your child have any allergies? None ___ Yes ___ (If yes please describe)
Specify Allergies (Medication, food, environment, or other)
Medical Exam(This page to be done by physician)
Student’s Name (last, first,M.): Entering Grade Date of Birth(yyyy/mm/dd):
Dear Doctors : For the items that you don’t think necessary for this child. Please be strict on immunization.
If you cannot find any records of immunization, please administer appropriate immunization. TB skin test should be administered every other year.
Please administer the following tests as well as any others needed.
GSIS require evidence of immunization for the following:
DPT #1 #2 #3 #4 #5 OPV(polio) #1 #2 #3 #4 MMR #1 #2 DT
TB skin test(every two years) date Result
I have seen evidence that these have been administered. Yes No
Please be strict on immunization. Students who have lost records must have one OPV, DT, MMR booster along with the Tuberculin skin test.
Please administer appropriate immunization to complete records.
I certify that this student has been examined by me. This examination shows that this student is physically able to participate in physical education activities,
Including inter-scholastic sports, unless otherwise specified above.
Physician’s Signature Clinic/Hospital
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