Student Health Form

OIS - Oeiras International School, ASFL Quinta N. Srª da Conceição - Rua Antero de Quental, Nº 7- 2730-013 Barcarena, Portugal.

Tel: +351 211 935 330. www.oeirasinternationalschool.com NIPC 509 303 498 AEEP nº 1152 1

First and Last Name

Date of birth: (dd-mm-yyyy)

Blood Group A, B, AB or O. / - (negative) or +(positive)

Vaccinations Is your child following a vaccination program? Please be informed that both Diphtheria and Tetanus vaccinations are mandatory in Portugal.

Do you want the nurse to keep you updated about upcoming vaccinations?

When did your child have his/her last Diphtheria and Tetanus vaccination (Dt)? dd-mm-yyyy

Medical information: Has your child ever had any of the following problems? (Only mark if YES and please specify below) Allergies; seasonal/hay fever/food1 Behavioural Problems Chronic ear infections add/adhd

Allergy; life threatening/anaphylaxis1 Developmental Problems Frequent Headaches asthma1

Anaemia or other blood problems Eczema/Chronic Skin Condition Heart disease Cancer

Blood Pressure Problems (High/Low) Frequent Stomach aches Kidney disease Depression

Chronic Diarrhoea or Constipation Hearing/Ear Problems Learning problems Diabetes1

Emotional/Psychological Problems Seizure Disorder/Epilepsy/Tics1 Sleep Problems Other:

Eye problems/Glasses/Contacts Tooth/Dental Problems Speech Problems

Allergies, (include food, medications, environmental, seasonal, etc.):

Does your child see a specialist? If yes, please list condition, doctor’s name, and phone number:

Condition:

Name doctor: Phone no

I give permission for the nurse to contact our child’s specialist if she has any more questions. I give my permission for our child´s specialist to share information with the Registered Nurse.

Please list any medications (prescribed or over-the-counter) your child takes at home on a daily or as-needed basis (such as medication for ADHD, allergies, asthma, or headaches): Condition: Name Medication: Daily Dose:

Illnesses in family Did your child suffer from any of the following diseases? (mother, father, siblings) Pertussis (whooping cough, coqueluche) Allergies Measles (sarampo) Diabetes Mumps (parotitis, caxumba) Seizure disorders Chicken pox (varicella) Other Rubella (rubéola)

Student Health Form

OIS - Oeiras International School, ASFL Quinta N. Srª da Conceição - Rua Antero de Quental, Nº 7- 2730-013 Barcarena, Portugal.

Tel: +351 211 935 330. www.oeirasinternationalschool.com NIPC 509 303 498 AEEP nº 1152 2

I have read and understood the Medication Administration Policy (attached).

Please indicate whether you give permission for the school nurse and designated personnel to administer over-the-counter medication like pain relievers, anti-inflammatory medications and anti-histamines, throughout the school year.2

Please indicate whether you give permission to share information with the school health team.

I give permission for my child to participate in the health screenings3.

In the event of an accident and the school being unable to contact a parent, do you give consent for a representative of the school to give permission for medical treatment? Any student who is required to take medication prescribed for him/her by a doctor, may be assisted by the school nurse or other designated school personnel, providing the school receives the “Permission to give (non) prescription medication” form. This form needs to be signed at the start of every school year or if the student has a new prescription. (see the medication policy).45 If your child requires medication on an intermittent basis (such as for asthma), this medication should be left with the school nurse, together with the “Permission to give (non) prescription medication” form, and it will be stored in a locked cabinet, labelled with the child’s name and dosage.6 If your child is allowed to take his/her own medication at school the “Contract for students carrying medication at school” needs to be signed by both student and parents/guardians. This form needs to be signed at the start of every school year.

Medical treatment in case of emergency

In the event of an accident and the school being unable to contact a parent, do you give consent for a representative of the school to give permission for medical treatment?

Health insurance membership:

Name of family doctor: tel nº:

Please confirm details of one other person who may act in loco parentis should the school be unable to reach you in an emergency.

Name:

Tel nº:

Contact Details:

Father’s /guardian’s mobile nº business tel.Nº

Mother’s /guardian’s mobile nº business tel.Nº

Additional information:

Name of parent / guardian: Date: (dd-mm-yy)

Signature

1 Please fill in the appropiate Care Plan. They are available at the Health Office. 2 Parental or guardian request/permission should be renewed annually, or more often, if necessary. 3 Information about health screenings: “Purpose of health visits” attached. 4 Written parental consent and request to administer medication is required for each medication ordered and for each new order (even if the medication was previously given in school). Parental consent is required as a part of the authorization (see the Medication Policy) and is required before medications will be administered. 5 Please see attachment for explanation of all Health Forms. 6 Prescription and medication supply renewal should be the responsibility of the parent/guardian.

You can send the form by email, please save it with your child´s name.