Medical Records

Medical Records

No medication will be dispensed to your child until this form is submitted.
Student Details
Student Name*

First NameLast Name
Year Level*
Birth Date*

MonthDayYear
Gender*
Family Doctor*
Family Doctor Phone*
Parent/Guardian/Caregiver 1 Details
Parent/Guardian/Caregiver 1 Name*

First NameLast Name
Email*
example@example.com
Relationship to Applicant*

	Yes / No	Medication	Plan of Action
Allergies (please specify)
Anaphylaxis
Asthma
Diabetes
Cardiac Problems
Depression/Psychological issues
Dietary Issues e.g. coeliac, gluten free
Epilepsy
Headaches/Migraines
Physical Disabilities
Hearing e.g. hearing aid
Vision e.g. wears glasses/contact lenses

	Yes	No
Paracetamol (if clinically indicated)
Antihistamine (if clinically indicated)
Ibuprofen (if clinically indicated)

Student Details