Passport sized photograph of child MEDICAL FORM Child’s Name: Child’s Date of Birth: Gender: Boy Girl Name of Doctor (Clinic): Clinic / Mobile No.: Y N Type of Illness Y N Measles Diabetes Type 1 or 2 German Measles Epilepsy Chicken Pox Heart Trouble Mumps Rheumatic Fever Whooping Cough Asthma Scarlet Fever Convulsions Hand, Foot & Mouth Disease Kidney Disease Infectious Hepatitis Tuberculosis Poliomyelitis Hearing Difficulty Pneumonia Vision Difficulty Malaria Speech Difficulty Meningitis Rheumatism Chronic illness Skin Disorder / Eczema Bronchitis Convulsions Child’s Pediatrician Details: Child’s Health History (Please indicate if your child has had any of the following conditions / illnesses) Type of Illness
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Passport sized photograph of
child
MEDICAL FORM
Child’s Name: Child’s Date of Birth: Gender: Boy Girl Name of Doctor (Clinic): Clinic / Mobile No.:
Y N Type of Illness Y N
Measles Diabetes Type 1 or 2 German Measles Epilepsy Chicken Pox Heart Trouble Mumps Rheumatic Fever Whooping Cough Asthma Scarlet Fever Convulsions Hand, Foot & Mouth Disease
Child’s Health History (Please indicate if your child has had any of thefollowing conditions / illnesses)Type of Illness
Do you Need to supply the nursery with Medication for your child? If yes, please give detailsof the medications and the reasons for this:
Administration of ‘over the counter’ medicine
Emergency Treatment
Name : …………………….............…
Signature : ………………………………… Date : …………………………..
In the Event of an emergency, I here by authorize the SBN staff to take my child to a doctor or to the hospital for treatment or call an ambulance, and any expense of this service will be acceppted by me.
I give my permission to the nursery to administer Adol/Calpol Syrup (pain/fever reliever), If my child develops a fever, or has pain, or a mild allergic reaction.
MEDICAL CONSENT
For Display on Classroom & Nurse’s Information Board
Full name of Child (Write in BLOCK CAPITAL LETTERS)
I am Allergic to: ______________________________________________________________