LEARNER HEALTH PROFILE

Name

Surname

Date of Birth

Gender

Male

Female

Particulars of doctor who treats your child (Private or Government):

General Practitioner

Name

Phone

Specialist Doctor

Name

Phone

Medical Aid Details: (Please submit a copy of Medical Aid Card)

Name of Medical Aid:

Medical Aid Number:

Plan/ option:

Medical Information (Please submit letter of diagnosis and reports)

Primary Diagnosis:

Treating Doctor:

Current Medication (A copy of the script HAS to be provided every 6 months)

Is your child currently on medication?

Yes

Allergies

Does your child have any allergies?

Yes

If yes, please explain:

Is your child on a special diet?

Yes

If yes, please explain:

Does your child have any other illness?

Yes

If yes, please explain:

Immunizations and Screening (Please provide a copy of the immunization record)

Immunization done on standard schedule

Yes

Declining all immunizations

Yes

Selective immunizations or delayed schedule

Yes

MEDICAL HISTORY OF LEARNER

Please tick the condition your child might have had and the age:

Chicken pox

Yes

Epilepsy, Convulsions

Yes

Measles, Rubella

Yes

Bed-wetting (over 3 years)

Yes

Whooping cough

Yes

Hay fever

Yes

Scarlett fever

Yes

Vision or eye problems

Yes

Rheumatic fever

Yes

Chronic ear infections

Yes

Asthma

Yes

Hearing loss

Yes

Heart problems

Yes

Diabetes

Yes

Hepatitis

Yes

Thyroid problems

Yes

Mumps

Yes

Other illness:

Yes

What other illness?

SURGICAL HISTORY

Previous surgeries:

Name of procedure

Year

Name of procedure

Year

Name of procedure

Year

Name of procedure

Year

Name of procedure

Year

MEDICAL HISTORY (MOTHER)

Birth History

Was your child premature?

Yes

Duration of pregnancy (weeks):

Method of delivery

Normal Vaginal Delivery

Caesarean Section

Forceps

Were there any complications during labour or delivery?

Yes

If yes, explain:

Apgar Score:

Length in cm:

Weight in kg:

Head circumference:

Was the baby on a ventilator?

Yes

If yes, for how long?

Did the baby have jaundice after birth?

Yes

Did the mom have post-natal depression?

Yes

Were there any other illnesses during pregnancy

Yes

If yes, please explain:

Alcohol consumption during pregnancy

Yes

If yes, how much?

Frequently

Occasionally

Rarely

Smoking during pregnancy

Yes

If yes, how much?

Daily

Occasionally

Substance abuse during pregnancy

Yes

Emergency Arrangements

Your child’s health is your responsibility. If your child is in need of medical care, it is your responsibility to take your child to a doctor or clinic for treatment. The school is not equipped to treat your child. This rule is also applicable especially to parents/guardians with children at hostel. In case of a life-threatening emergency and where the child’s parent/guardians cannot be contacted, the child will be taken to the nearest emergency department.

Please state whom the school can contact in case of an EMERGENCY if you are not available:

Name

Phone

Name

Phone

Name

Phone

In case where your child becomes sick during School Hours, the School Sister can give symptomatic treatment as a temporary measure. If this treatment does not work, you will be asked to fetch your child from school/hostel for medical treatment. Please note that in case of any contagious disease or suspicion of a contagious disease you will need to fetch your child immediately from school/hostel and take for further medical treatment. No child will be allowed at school/hostel until the School Sister has received a letter from the clinic/doctor stating that the disease is no longer contagious. We need to protect the other learners in the school as well as our staff members.

I, the undersigned Parent/Guardian of understand the rules and will abide by them.

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