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New student health form 2013

All students newly admitted to Dwight School Seoul must complete and submit this health form prior to the first day of school. Page 3 of this form must be completed by a physician. The family is welcome to select a physician outside of Korea. If any of the information provided on this form changes during the school year, please notify the school Nurse immediately.
Student Information
Medical History
If you have answered YES to any of the above, please explain in detail. _______________________________________________________ _______________________________________________________________________________________________________________________ Has your child ever had surgery/hospitalization in the past? If yes, please provide date(s) and details. ____________________________ _______________________________________________________________________________________________________________________ Is your child currently receiving any regular medicine or medical treatment? If yes, please provide details. ________________________ _______________________________________________________________________________________________________________________ Do any of the above-mentioned conditions prevent your child from participating in physical education/sports activities? If yes, please describe any limitations and attach a doctor certificate. _______________________________________________________________________________________________________________________ Immunization Record: Please print the exact dates of vaccinations r
Immunization Recor
eceived (mm/dd/yy)
d: Please print the exact dates of vaccinations r
DPT/DTaP (diphtheria,
MMR (measles, mumps,
Hepatitis B
Varicella (chicken pox)
tetanus & pertussis)
rubella)
Td/Tdap (tetanus & diphtheria)
Medical Permission I give my permission for authorized school staff to administer non-pr
I give my permission for authorized school staf
escriptive medicines as is thought appr
f to administer non-pr
opriate and necessary
escriptive medicines as is thought appr
opriate and necessary
Acetaminophen (Tylenol) - pain & fever relief Sudafed (non-drowsy) - for nasal/sinus congestion Ibuprofen (Advil) - pain relief & anti-inflammatory ) - stomach indigestion, nausea, diarrhea Emergency Care Permission
I hereby give permission for emergency measures to be taken by authorized school staff in case of accident or sudden illness, and understand that I will be notified as soon as possible.
I certify that all information provided on this form is complete and correct, and acknowledge that it is my responsibility to inform Dwight School Seoul Nurse's Office of any changes in my child's health or medical needs.
Parent Signature ________________________________ Print Name: __________________________________ Date (mm/dd/yy): __________ Physical Examination Report To be completed by a qualified licensed physician or nurse practitioner
Please return this completed form to the Nurse's office prior to the first day of school. Failure to submit this document may result in students being denied participation in physical education and other sports activities.
Student Name: ______________________________________________________________________ Date of Birth (mm/dd/yy): ____________ ABNORMAL
ABNORMAL
Please administer the following tests
Date (mm/dd/yy)
Tuberculosis Skin Test OR Chest X-ray
(If TB skin test is positive, chest x-ray is required) Hemoglobin
(Students age 5 and above only)
Urinalysis
Please check for evidence of the following immunizations. Please be strict with immunizations. Students who have lost recor
Please check for evidence of the following immunizations. Please be strict with immunizations. Students who have lost r
ds must have
an IPV, DPT
, MMR booster and TB skin test. Please administer appr
opriate immunizations to complete r
, MMR booster and TB skin test. Please administer appr
opriate immunizations to complete r
I certify that this student has been examined by me. This examination shows that this student is physically able to participate in physical education activities, including inter-scholastic sports, unless otherwise specified above.
Physician Name: _________________________________________ Physician Signature: ___________________________________________

Source: http://www.dwight.or.kr/wp-content/uploads/2013/05/New_Student_Health_Form.pdf

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