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Medical and Immunisation Record and Consent Declaration .pdf


Original filename: Medical and Immunisation Record and Consent Declaration.pdf
Author: Sandi McGuinn

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Medical and Vaccination Record and Consent Declaration
To be completed and returned to the Admissions Team, BIS Abu Dhabi

CONFIDENTIAL

Pupil Name ________________________________________________________

Date of Birth _________________________________________________________

Please note that this form should be completed and returned to BIS Abu Dhabi prior to your
child commencing school.

Passport Size
Photograph

The Abu Dhabi Education Council (ADEC) and The Department of School Health requires
accurate vaccination records on each child registered within the Abu Dhabi schools
system. It is essential that we are able to present them with accurate records of each
child’s immunization status. Please supply a copy of your child’s vaccination certificate,
along with this completed form.
Personal Information

Details:
Child’s Name

__ Date of Birth _____________________

Nationality __________________________ Gender _________________ Class/ Year ________________
Father’s Name _____________________________ Mother’s Name ______________________________
Address _______________________________________________________________________________
______________________________________________________________________________________
Contact Numbers:
Home ______________________________________ Office ____________________________________
Mother’s Mobile _____________________________ Father’s Mobile _____________________________

Child’s Medical History
Illnesses

Yes
(Date)

No

Conditions

Chicken Pox

ADHD

Diphtheria

Allergies / Eczema

Infective Hepatitis

Bronchial Asthma

Measles

Congenital Heart Disease

Mumps

Diabetes Mellitus

Poliomyelitis

Epilepsy / Seizures

Rheumatic Fever

Frequent Gastric Problems

Rubella

Frequent Headaches

Scarlett Fever

Hearing Problems

Tuberculosis

Nocturnal Enuresis

Whooping Cough

Serious Accidents / Fractures

Other

Thalassemia / G6PD
Vision Problems / Glasses
Other

Family History:
Diabetes / Hypertension / Epilepsy / Stroke / Tuberculosis (please circle where applicable).
Others, please specify: _________________________________________________

Yes
(Date)

No

For any ‘Yes’ responses in the child’s medical history, please provide more details, including treatment, dates
and any medication taken on a regular basis:

Note: If your child commences any new medication, treatment, or changes his/her existing medication, the
school nurse must be informed accordingly.
Child’s Vaccination Record
Kindly indicate the date immunization was administered under the appropriate columns, and include a copy of
your child’s original Vaccination record for verification.
The Department of School Health requires that the School maintains current information of each child's
vaccination history. Therefore, it is important that this form is fully completed.
Please print clearly in BLOCK LETTERS to enable Health Care Staff to clearly interpret the information.
Type of Vaccination

1st Dose
(Date)

2nd Dose
(Date)

3rd Dose
(Date)

Booster
(Date)

Remarks

BCG
BCG Screening
Hepatitis B
DPT
Polio
Hib
Measles
MMR
D.T
Chicken Pox
Rubella
HPV
Others

I confirm that all medical history information provided is correct, and the above is a true record of my
child's vaccination history.
Name of student: ______________________________________________ Date of Birth: _______________
Name of parent: _________________________________________________
Signature: ______________________________________________________ Date: ___________________

Consent for the Administration of Medications
As the parent/guardian of _____________________________________________ (Child's full name), born on
__________________________ (date of birth), I give my consent to the following:
In the event that my child develops a fever, pain , has an allergic reaction, or he/she has injured him/herself, it may
be necessary to administer specific medication or undertake treatment. I have read and understood the list of the
medications or solutions used at the School.
If my child is unable to use any of these medications, I will contact the School Nurse to discuss the use of an
alternative.
This is to authorize the School Nurses to administer the appropriate drugs for the various situations that may arise,
subject to the notification that an alternative be used.
Name of drug

Age

Dose

Indication

Remarks

Paracetamol Syrup

1 - 4 years

15mg/kg/ dose

Pain, Fever

Every 4 - 6
hours

5-12 years; 5-10ml
12-18 years; 10ml

15mg/kg/ dose

Pain, Fever

Every 4 - 6 hours

Under 30kg
Over 30kg

5ml

Allergy, insect bite

Every 8 hours

Fenistil Gel

All

-

Allergy, insect bite

Every 8 hours

Panadol Tab (500mg)

12 and above

1-2 tablets

Pain, Fever

Repeat after 4
- 6 hours

Saline Nasal
Spray/ Drop

All

1 Puff/ Drop in
each Nostril

Blocked nose

As required

Reparil Antiinflammatory Gel

All

-

Muscular
trauma/
swelling

Once daily

Optrex Eye Wash

As per instructions

Sand/ Dirt in Eyes

-

As required

120mg/5mg
Paracetamol Syrup
250mg/5mg
Claritine
5mg/5ml

10ml

I consent to my child being given the above medication should it be considered necessary by the school
nurses.
Name of parent: _________________________________________________
Signature: ______________________________________________________ Date: ___________________

Consent for Emergency Treatment
In the event that my child requires emergency treatment, I will be contacted and asked to collect my child from
School.
If the School is unable to contact me, my child will be taken to a doctor or hospital for diagnosis and treatment.
Efforts to contact me will continue.
I consent to my child being taken to a doctor or hospital in the event of a medical emergency.
Name of student: ______________________________________________Date of Birth: _______________
Name of parent: ________________________________________________
Signature: ____________________________________________________ Date: _____________________
Emergency Contact number: ______________________________________

Preferred Hospital: _______________________________________________________________________
Name of Doctor: __________________________________________________________________________
Hospital/Doctor contact number: __________________________________

Health Screenings
Throughout the year the school nursing team are required to undertake mandatory school health screening for
years 1-13. This is an annual basic screening program. The screening tests include medical history, Body Mass
Index (BMI percentile) and vision screening. The health data is submitted to the Health Authority of Abu Dhabi.
At the time of screening the health data is not shared with your child or any other staff within the school. The
School Nurse will be present for the duration of all screenings. Any findings requiring additional follow up or
referrals will be reported to the parents using the Parents Notification Form.
If you have any queries or concerns regarding this examination, please contact the School Clinic Manager or
your child's physician.

I CONSENT / DO NOT CONSENT to my child to be examined by the School Nurses during the Health
Screening Program.

Name of student: ______________________________________________ Date of Birth: _______________
Name of parent: _________________________________________________
Signature: ______________________________________________________ Date: ___________________

Infection Control Policy
In order to reduce and minimise the spread of illnesses in the School, the following regulations shall apply.
Please do not send your child to the School if they have:








A fever (not to return to School for 24 hours after the last fever episode)
A skin rash
Vomiting (not to return to School for 24 hours after the last vomiting episode)
Diarrhea (not to return to School for 24 hours after the last diarrhoea episode)
A persistent cough
A heavy nasal discharge
Red, watery and painful eyes

If they have an infected sore or wound, it must be covered by a well-sealed dressing or plaster.
If your child is assessed by the School Clinic Manager and/or School Nurse, and deemed to be a possible source
of infection to other students, you will be contacted to bring them home immediately.
Please inform the School if your child has been or is being treated or under medication for a medical condition.

Dietary Information
Special dietary requirement?
 Vegetarian
 Halal
 Lactose intolerance
 Non-dairy Wheat-free Gluten-free Nut-free

Please circle where applicable Yes/No
Yes
No
Yes
No
Yes
No
Yes
No

Please note any other requirements or restrictions we should be aware:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________
I have read and understood the School’s Infection Control Policy and agree to abide by the policy. I have also
advised, to the best of my knowledge, any special dietary requirements and intolerances.

Name of student: ________________________________________________ Date of Birth: _______________
Name of parent: _________________________________________________
Signature: ______________________________________________________ Date: ___________________


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