New Era High School
Medical Report
PLEASE PRINT THIS FORM AND FILL THE FORM IN CAPITAL LETTERS (UPPERCASE ONLY).
Submit this along with application form duly filled, signed and stamped by your Family Doctor
| Date: | |
| Name Of The Student: | |
| (First Middle Last) | |
| Age: | Date Of Birth: |
| Sex: | |
| Present Standard Or Class: | |
| Date Of Admission To The School: | |
| Any illness (physical or psychological) of father or mother | |
| Any Other Family Illness | |
| Is the child having any illnes? (explain) | |
| Country Of Birth | |
| Country Of Residence | |
| Parents Signature | |
| Full Name Of Parents | |
PERSONAL MEDICAL HISTORY(To Be Filled In By The Family Doctor) | |
| Name Of The Family Doctor: | |
| Full Address | |
| Tel. No. (Plus Area Code) | |
| Fax | |
| Person(s) To Contact In Case Of Emergency: | |
| Relationship | |
| Full Address | |
| Phone (Plus Area Code) | |
| Altertnative Phone | |
| Fax | |
| Student’s Blood Type: | |
Has the child ever had or does he or she now have any of the following? (If any answer is yes, please write the year) | |||
| Particulars | Yes | No | Year |
| Severe Headaches | |||
| Eye Trouble | |||
| Ear Trouble | |||
| Allergies Or Hay Fever | |||
| Other Lung Or Breathing Problems | |||
| Hemophelia | |||
| Low Blood Pressure | |||
| Asthma | |||
| Heart Trouble | |||
| Anemia | |||
| Hepatitis Or Other Liver Problems | |||
| Hernia | |||
| Epilepsy | |||
| Particulars | Yes | No | If Yes, please explain |
| Fainting Spells | |||
| Skin Disease Or Problems | |||
| Recurrent Tonsillitis | |||
| Chicken Pox | |||
| Rheumatic Fever | |||
| Tuberculosis/ Positive T.B.test | |||
| Typhoid | |||
| Nephritis | |||
| Diptheria | |||
| Malaria | |||
| Diabetes | |||
| Tumor/cancer | |||
| Blood Transfusions | |||
| Physical Handicaps | |||
| Has Received Psychotherapy | |||
| Is Under A Doctor’s Care Now | |||
| Has Had Any Serious Illness Or Injury | |||
| Bed Wetting | |||
| Speech Defect | |||
| Does Child Have Any Contageous Disease Or Infection At Present? | |||
| Any Allergy To Drugs Or Medicine (Name them) | |||
| Any Other Problems (Name them) | |||
| Any other special observation, recommendation or information the school should know | |||
| List medications (prescription or non-prescription currently being taken by the child | |||
| Has the child ever been hospitalized for any illness, injury or operation? If yes, please list, giving reasons and dates: |
FAMILY HISTORY | |||
Has anyone in the child’s family had or now has any of the following: (If yes, please explain.) | |||
| Particulars | Yes | No | If Yes, please explain |
| Diabetes | |||
| Kidney Disease | |||
| Schizophrenia Or Manic-depressive Disorder (or Other Psychological Problem) | |||
| PLEASE NOTE: WITHHOLDING ANY INFORMATION CONCERNING THE ABOVE CONCERNING PHYSICAL AND MENTAL HEALTH MAY BE GROUNDS FOR ADMISSION BEING CANCELLED LATER ON. | |||
DOCTOR’S SIGNATURE & STAMP: | |||
