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Please complete this health information form and return it to the school nurse by the first day of classes.
The information provided will remain confidential by all staff.
Name of Student:
Grade:
Nationality:
Date of Birth:(d/m/y)
Residence number:
Mothers mobile:
Fathers mobile:
Alternative number:
Gender:
Male (M)
Female (F)
Has your child had any of the following? If yes, please specify the dates.
INFECTIOUS DISEASE
Diphtheria
Dysentery
Infective Hepatitis
Measles
Mumps
Poliomyelitis
YES
NO
Rubella
Scarlet Fever
Tuberculosis
Whooping Cough
Chicken Pox
Other
NON-INFECTIOUS DISEASE
Allergies, specify:
Bronchial Asthma
Congenital Heart Disease
Diabetes Mellitus
Epilepsy
G6PD(Glucose 6 Phosphate Dehydrogenase
deficiency)
Rheumatic Fever
Thalassemia (blood disorder)
Frequent headaches
Vision problems
Hearing Problems
Nocturnal Enuresis
Other
If you answered YES to any questions above, please add details below.
Family History:
Diabetes Hypertension
Stroke
Tuberculosis
No
YES
NO
Name of student:
Grade:
M/F
No
Emergency Treatment
The school nurse will attempt to contact you should an emergency arise. In the event parents cannot be contacted, I authorize and
empower the School Nurse or a School Administrator to make any and all decisions concerning the medical and/or surgical care of my
child, which may include taking the child to a doctor or hospital for emergency treatment.
Yes
No
School M edicals
The UAE Department of Health and Medical Services requires that all students in both private and public school entering Pre-K,
Kindergarten and Grades 1, 5, 9 and 12, as well as all new students must have a clear Medical Health examination filed in the GWA
Medical Centre. This examination may be undertaken by the doctor of your choice. School medicals will be conducted throughout the
year by our licensed school doctor.
Yes
No
I consent to my child having a school medical, conducted by the school doctor, if in the above
specified grades or upon school entry.
Yes
No
I will arrange my own private medical appointment by a registered physician and will submit
the required report to the GWA Medical Centre within timelines required.
Class/Grade: ________