Student Medical Record 学生医疗记录

Student Medical Record
学生医疗记录

The school Health Centre requests health information of your child through this form. Please fill in the necessary information. This will serve as the child's record in the clinic. If you have any question, you can contact our school at +65 6524 0500. 按照学校保健中心要求，家长需提供学生的健康信息。请按要求填下表格信息。这些信息将在学校医疗室存档作为学生的医疗记录。如有任何问题，请联系我们 +65 6254 0200。

Please affix a recent passport-size photograph 请附上1张护照型近照

Maximum file size: 2 MB

Student Name/ 学生姓名 *

Gender/ 性别 *

Date of Birth/ 出生日期 *

Age/ 年龄 *

Name of Parent or Guardian/ 父母或监护人姓名 *

Contact Number/ 联系号码 *

1. CHILD'S LEARNING NEEDS 学生学习状况

Has your child/ward ever had (Please submit all pertaining documents) 请问您的孩子是否有病例情况（请提交相关文件）

Enrichment or remedial help（强化或治疗的协助） *

A learning difficulty（学习障碍） *

A behavior difficulty（行习障碍） *

Psychological assessment/treatment（心理治疗） *

2. HEALTH 学生健康状况

Does the student have any problems with the following? / 学生是否有以下病历？

Asthma/ 哮喘 *

Diabetes/ 糖尿病 *

Epilepsy/ 癫痫 *

Other Illness/ 其他病症 *

If yes, please state/ 如果有，请注明

Allergies to any medicine, food(eg: Nuts, seafood, eggs) 对哪些食物过敏（如：花生、海鲜、蛋类） *

If yes, please state/ 如果有，请注明

Are you taking any medication/ treatment at present? 目前是否正接受任何治疗？ *

If yes, please state/ 如果有，请注明

Does the student have any problems with the following? / 学生是否有以下障碍？

Hearing/ 听力 *

Speech/ 语言 *

Sight/ 视力 *

Remark(s) 备注

Please submit a copy of Immunization Record to us/ 请提供一份疫苗接种记录给我们。

Maximum file size: 10 MB

Emergency Treatment Authorization: In the event of emergency when immediate observation or treatment is deemed necessary in the judgement of the school nurse and authorities, I authorize and direct the school authorities to send my child to the medical facility most readily accessible.
急诊治疗授权：在紧急情况下，若经学校护士或者相关专业人士判断，学生需立即就医观察或者治疗，我授权并允许校方将孩子送往最适当的医疗机构。

Parent/ Guardian Signature 家长/监护人签名 *

Date