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Student Medical Form Student
Dear Parent/ Guardian of the Student:
Please fill the following form accurately to ensure maintaining and monitoring your child’s health and wellbeing during the school year
School Information
School Name: ………………………………………………………………………………………………….. Grade: ……………………….. Section: …………………………………
Student Information
Student Full Name: …………………………………………………………………………….. Gender: ………………………………………………………………………………
Date of Birth: ……………………………………………………………………………………….. Nationality: ……………………………………………………………………….
Parent or Legal Guardian Name: ……………………………………………………… Relationship: …...................................................................................
Mobile Number (1): ……………………………………………………………………………. Mobile Number (2): …………………………………………………………
E-Mail: ………………………………………………………………………………………………….. Emirate: ………………………………………………………………………………
In case of Emergency and we are unable to reach the parent/guardian, the following person can be contacted:
Name: …………………………………………………… Relationship: ……………………………………… Mobile Number: ….........................................................
Required Attachments
Student’s Emirates ID Copy Yes No ID Number: …………………………………………………………………………………….
Student’s Passport Copy Yes No
Original Vaccination Card or
Yes No
Updated Copy
Health Card Copy (if any) Yes No Health Card Number: …………………………………………………………………..
Health Insurance Card Copy
Yes No
(if any)
Student Medical History
Health Problem Yes No Comments
1 Does the student suffer from any allergy to medicine,
food, dust, etc.?
If yes, please specify in comments
2 Does the student suffer from any Cardiovascular problem?
3 Does the student suffer from Diabetes?
4 Does the student suffer from Hypertension?
5 Does the student suffer from Bronchial Asthma?
Student Medical Form Student
6 Does the student suffer from any Renal Problem?
7 Does the student suffer from Epilepsy or Convulsion
Seizures?
8 Does the student suffer from Epistaxis?
9 Does the student suffer from Hemolytic Anemia, type
G6PD?
10 Does the student suffer from any Hereditary Blood
Disease (e.g. Thalassemia, sickle cell anemia, Hemophilia)?
If yes, please specify in comments
11 Does the student suffer from any Skin Problem?
12 Does the student suffer from any Eye problem (Myopia,
Hyperopia…)?
If yes, please specify in comments
13 Does the student suffer from any Hearing problem?
14 Dose the student use any medical aid device?
If yes, please specify the device details in comments
15 Did the student undergo any surgery in the past?
If yes, please specify the details in comments
16 Was the student ever hospitalized?
If yes, please specify the reasons in comments
17 Does the student have any health condition that could
weaken the immune system such as Cancer (Blood cancer,
Lymphoma), or an organ transplant?
If yes, please specify in comments
18 Did the student get any blood, antibodies or plasma
Transfusion in the past?
19 Did the student suffer from any of the following diseases:
(Mumps, Measles, Diphtheria, Pertussis, Chickenpox,
Tuberculosis),
If yes, please specify details in comments
20 Did the student suffer from Viral Hepatitis?
21 Did the student suffer from Poliomyelitis (Infantile
Paralysis infection)?
Student Medical Form Student
22 Does the student suffer from any Mental or Behavioral
Problem?
If yes, please specify in comments
23 Does the student suffer from any other Problem or
disease not mentioned here?
If yes, please specify in comments
Student Medical Form Student
If the student suffer/suffered from any of the health problems mentioned or not mentioned above, please answer the following questions
Medications or Treatments taken continuously
Medicine Name: ………………………………………………………………………….. Dosage: …………………………………………………………………………………..
Emergency Medications
Medicine Name: …………………………………………………………………………. Dosage: ……………………………………………………………………………………
Any treating Doctor instructions on Student’s nutrition
…………………………………………………………………………………………………………………………………………………………………………………………………………..
Any treating Doctor instructions on Student’s physical activity and exercise
…………………………………………………………………………………………………………………………………………………………………………………………………………..
Any treating Doctor instructions for Student’s School Doctor/Nurse to apply during the school day
……………………………………….
............................................................................................. ....................................................................................................... ............................
Family Medical History
Health Problem Yes No Comments
1 Any Cardiovascular problem and Hypertension
2 Diabetes
3 Any Hereditary Blood Disease (e. g. Thalassemia,
sickle cell anemia, Hemophilia)
4 Any type of Cancer
5 Any Immune System problem
6 Any Mental Health problem
7 Others, please specify in comments
Student Medical Form Student
Parent/ Guardian approval and verification for the above mentioned information
Parent /Guardian Name: ………………………………………………………………………… Relationship: ………………………………………………….
Parent/ Guardian Signature: ………………………………………………………………….. Date:…………………………………………………………….
Notes
Please attach medical reports about the Student’s health problem, if any
The parent of legal guardian of the student should fill this form. He or She is responsible for the above-
mentioned information.
Parents and Legal Guardians are responsible for informing school nurse about any change that occur in
health status of the student. They should provide the school nurse with the required reports needed to
be added in the student health file
Please contact school nurse or doctor if there is any further queries
