Learner Health Profile

Names:

Surname:

Date of birth:

Gender:

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

General Practitioner

Name: Telephone Number:

Specialist Doctor

Name: Telephone Number:

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?
YesNo

Allergies

Does your child have any allergies?
YesNo

If yes, please explain:

Is your child on a special diet?
YesNo

If yes, please explain:

Does your child have any other illness?
YesNo

If yes, please explain:

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

Immunization done on standard schedule
YesNo

Declining all immunizations
YesNo

Selective immunizations or delayed schedule
YesNo

MEDICAL HISTORY OF LEARNER
Please tick the condition your child might have had and the age:

Condition

SURGICAL HISTORY

Previous surgeries:
Name of procedure: Year:

MEDICAL HISTORY (MOTHER)

Birth History

Was your child premature?
YesNo

Duration of pregnancy: weeks

Method of delivery
Normal Vaginal DeliveryCaesarean SectionForceps

Were there any complications during labour or delivery?
YesNo

If yes, please explain:

Apgar Score:

Weight in kg:

Length in cm:

Head circumference:

Was the baby on a ventilator?
YesNo

If yes, for how long?

Did the baby have jaundice after birth?
YesNo

Did the mom have post-natal depression?
YesNo

Were there any other illnesses during pregnancy
YesNo

If yes, for how long?

Alcohol consumption during pregnancy
YesNo

If yes, for how long?
FrequentlyOccasionallyRarely

Smoking during pregnancy
YesNo

If yes, how much?
DailyOccasionally

Substance abuse during pregnancy
YesNo

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: Contact Number:

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.