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Medical Checklist Form

Student Information
Full Name
Gender/Sex
Date of Birth
Grade
Class
National ID/Passport No

Parent/Guardian Information
Name of Parent/Guardian
Relationship to Student
Mobile Number 1
Mobile Number 2
Email Address

Medical History





Other (please specify):
Has your child ever been hospitalized?
Reason
Is your child currently taking any medication?
Name/Dosage

Immunization Record
Last vaccinations received
Date of last tetanus vaccine

Allergies



Other (please specify):
Does your child carry an EpiPen or allergy medication?

Emergency Information
Name
Relationship
Phone
Name
Relationship
Phone
Preferred hospital
Family doctor (if any)
Doctor’s phone

Permission & Consent

• - Paracetamol (Panadol) • - Antiseptic cream • - Antihistamine (for mild allergy)
• - باراسيتامول (بنادول) • - كريم مطهر • - مضاد للهستامين (للحساسية البسيطة)


في حالة الطوارئ، أوافق على تقديم العلاج الطبي لطفلي و/أو نقله إلى أقرب منشأة طبية

Signature of Parent/Guardian
Date