Student Medical Record

The school Health Centre requests health information of your child through this form. Please fill in the necessary information.

This will serve as the child’s record in the clinic. If you have any question, you can contact our school at +65 6524 0500.

Please affix a recent passport size photograph

Student Name

Sex

Date of Birth

Age

Name of Parent or Guardian

Contact Number

1. CHILD'S LEARNING NEEDS

Has your child/ward ever had (Please submit all pertaining documents)

Enrichment or remedial help

Yes No

A learning difficulty

Yes No

A behavior difficulty

Yes No

Psychological assessment/treatment

Yes No

2. HEALTH

Does the student have any problems with the following?

Asthma

Yes No

Diabetes

Yes No

Epilepsy

Yes No

Other Illness

Yes No

If yes, please state

Allergies to any medicine, food(eg: Nuts, seafood, eggs)

Yes No

If yes, please state

Are you taking any medication/ treatment at present?

Yes No

If yes, please state

Does the student have any problems with the following?

Hearing

Yes No

Remark(s)

Speech

Yes No

Remark(s)

Sight

Yes No

Remark(s)

Please submit a copy of Immunization Record to us

Emergency Treatment Authorization: In the event of emergency when immediate observation or treatment is deemed necessary in the judgement of the school nurse and authorities, I authorize and direct the school authorities to send my child to the medical facility most readily accessible.

Parent/ Guardian Signature

Date

Have any question?
Contact us.

Have any question?
Contact us.

Have any question?
Contact us.

Student Medical Record