ZAMSE SENIOR HIGH TECHNICAL SCHOOL
STUDENT MEDICAL FORM
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
Student Information
Student Full Name: ……………………………………………………………… Gender: ……………………………………………
Date of Birth: ……………………………………………………..…………………. Nationality …………………………………….
Parent or Legal Guardian Name: …………………………………………… Relationship: …………………………………..
Mobile Number (1): ………………………………………………………………. Mobile Number (2): ……………………….
NHIS Number: …………………………………………………………
In case of Emegency and we are unable to reach parent/ guardian, the following person can be contacted:
Name: …………………………………… Relationship: …………………………………. Mobile Number: ……………………
Should be filled by a medical Doctor.
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 the comments
2 Does the student suffer from any Cardiovascular/Heart
problem?
3 Does the student suffer from Diabetes?
4 Does the student suffer from Hypertension?
5 Does the student suffer from any Kidney problem?
6 Does the student suffer from Epilepsy or Convulsion
seizures?
7 Does the student suffer from Epistaxis (Bleeding from the
nose)?
8 Does the student suffer from Anemia?
9 Does the student suffer from Bronchial Asthma?
10 Does the student suffer from any Hereditary Blood
Diseases (e.g. Thalassemia, sickle cell anemia,
Hemophilia)?
If yes, Pease specify in the comments
11 Does the student suffer from an Eye problem?
12 Does the student suffer from any skin problem?
Student Medical Form & General Consent
13 Does the student use any medical aid device? Such as
inhaler
If yes, please specify the device in comments
14 Does the student suffer from any Hearing problem?
15 Did the student undergo any surgery in the past?
If yes, please specify the details in the comments
16 Was the student ever hospitalized?
If yes, please specify the details 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, Chicken pox,
Tuberculosis)?
If yes, please specify details in comments
20 Did the student suffer from Viral Hepatitis?
21 Did student suffer from poliomyelitis (Infantile paralysis
infection)?
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
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 instruction for student’s school Doctor/ Nurse to apply during school day
…………………………………………………………………………………………………………………………………………………………..
Parent / Guardian approval and verification for the above-mentioned information
I certify that the above provided information are valid
Parent / Guardian Name: ……………………………………………………Relationship: ………………………………………
Parent / Guardian signature: ………………………………………………... Date: ………………………………….
Doctor / Med. Practitioner Name:
…………………………………………………………………………………………………………………….
Signature & Stemp: …………………………………………………………….. Date: ………………………………………
Notes
Please attach medical reports about the student’s health problem, if any
It is the responsibility of the student’s parent/ Guardian to inform the school clinic of any changes
in the student’s health status and submit medical reports accordingly to update the student’s
Medical Record at school.
