STUDENT MEDICAL HISTORY FORM
Students No.:____________
Dear Parents/ Guardian:
Kindly fill this form about the medical History of your son/daughter by answering YES or NO.
If any answer is YES, please provide us with dates and details. Answers should be as accurate as
posibble. The student's Health ois our priority.
STUDENT'S DATA
Student's Name : _______________________________ Gender : __________________
Nationality : __________________________________ School : ___________________
Date of Birth : _________________________________ Class :_____________________
Guardian's Name : _____________________________ Relation to Student : ________
Mother's Name : ______________________________ Contact # : _________________
Father's Name : _______________________________ Contact # : _________________
Religion : _____________________________________ 1st Language : ______________
Address : _____________________________________
Emirates I.D Number: ________________________________
No. Health Concerns Yes NO Comments
Does the Students have any allergy or
1. Sensitivity to medications/food..etc.
Please mention if any: _______________
Does the studentss suffer from any
2.
cardiac problems?
3. Is the student Diabetic?
4. Does the student have hypertension?
5. Is the student asthmatic? HIKA (cough with
wheezing and breathlessness?
6. Does the student suffer from renal problem?
7. Did the student suffer previously from
Urinaty Track Infections?
8. Does the student suffer from epilepsy/Seizure?
9. Is the student suffering from G6PD deficiency?
Does the student have any chronic blood disease?
10.
(Thalasemia, Anemia, Hemophilia..etc.)
11. Does the student suffer from Recurrent epistaxis
(Nasal bleeding)
12. Does the student have any skin problem?
at the back please….
No. Health Concerns Yes NO Comments
13. Does the student have any eye (opthalmology)
problems (visual disturbances)
14. Any previous surgical procedures done?
15. Any previous admissions to hospital? Pls mention.
Is the student using any hearing/visual/walking
16.
aids? If Yes, what is it?
Did the student ever get mumps. Measles, chicken
17.
pox?
Does the student suffer from any psychiatric/
18.
behavioural problems?
If the student has any health problem, kindly answer the following questions:
Type of problem/disease & date of onset : _______________________________
When was the last attack? _____________________________________________
Name of Hospital or Health center where the student is getting treatment/follow up :___________________
Name of treating physician :____________________________________________
Long term medication used by the student :
Name of Medication : ________________________________ Dose & frequency : ________________________
Medication recommended in case of Emergency : _________________________________________________
Dietary Recommendations : ____________________________________
Physical activity Recommendations : ____________________________
Reccomedations for the school nurse during the school hours : _______________________________________
Parent's/ Guardians Name & Signatures : Date : _____________________
Note :
Kindly attach Medical report with this form & send it back to the school nurse with the student .
Thank You!
