Asociacion escuelas lincoln

The American International School of Zagreb
Accredited by the Middle States Association of Colleges and Schools Authorized by the International Baccalaureate Organization
B. STUDENT MEDICAL HISTORY FORM (To be kept in the Medical Office)

Please answer all questions regarding the health of your child. All information will be kept confidential.
Family Name ________________________________ First Name _____________________________
Sex (M/F) ____________ Grade ___________________ Birth date (day/month/yr) ________________
Local Doctor’s name or Clinic used: ______________________________________________________
Telephone/Mobile #: __________________________________________________________________
In case of an emergency, if we need to take your child to the hospital:
Can we call
ambulance:

What health insurance do you have: ______________________________________________________
Please, provide a copy of your child’s health insurance card (front and back of card).

Student Health History: To be completed by a parent or guardian.
YES
Please check “YES” if your child has or has had any of the listed medical conditions;” NO” if not.
If checked “YES”, please explain ______________________________________________________
Voćarska 106 · 10000 Zagreb, CROATIA · Phone: (385 1) 46 80 133 · Fax: (385 1) 46 80 171 · aisz@aisz.hr · www.aisz.hr DOS/Admin · 5080 Zagreb Place · Washington, DC 20521-5080 The American International School of Zagreb
Accredited by the Middle States Association of Colleges and Schools Authorized by the International Baccalaureate Organization • Does your child have any allergies (food, medications, environment, insects, and animals)? If yes, please explain including his/her response to offending substance and recommended treatment for
effective relief:
_________________________________________________________________________________
• Does your child have any physical, emotional, or behavioral issues that may interfere with his/her learning? □ YES □ NO
If yes, please explain ________________________________________________________________
• At home does your child take any medication? (Including herbal, homeopathic and/or emergency medication such as an epipen or inhaler.) □ YES □ NO

If yes, please explain including name of medication, dosage, route of administration, and rationale for
administration. _____________________________________________________________________

AUTHORIZATION FOR ROUTINE HEALTH SCREENINGS
Permission for the School Medical Officer to perform a routine check of your child’s height, weight, test for
scoliosis, vision (using an eye chart), hearing (using an audiometer) periodically, or as requested by a teacher or
counselor.
□ YES □ NO

AUTHORIZATION FOR MEDICATION IN SCHOOL AND ON CLAS TRIPS
Permission to treat your child with over-the counter medication should your child require or request
medication:
• Paracetamol for fever, headaches or minor discomfort □ YES □ NO
• Ibuprofen for fever, headaches or minor discomfort □ YES □ NO
• Strepsils lozenges for minor soar throat □ YES □ NO
• Fenistyl or 1% Hydrocortisone for minor itchy rashes □ YES □ NO
• Antacid (Pepto-Bismol, Rupurut) – for minor upset stomach. □ YES □ NO
• Herbal cream – for soft tissues injuries □ YES □ NO

If your child requires an over-the counter medication during the school day (for example – cough syrup, eye
drops…. etc.), you will need to meet with the Medical Officer and complete a medication request form or send
an e-mail. If your child requires a prescribed medication, you will need to have your Physician complete the
medication request form available in the Medical office. Both you and your Physician must sign the necessary
paperwork for all prescribed medication that is to be given at school.
Parent/Guardian’s name
(Print) _________________________ (Signature) __________________________
(Date) __________________________________ (day/mm/yr)

Voćarska 106 · 10000 Zagreb, CROATIA · Phone: (385 1) 46 80 133 · Fax: (385 1) 46 80 171 · aisz@aisz.hr · www.aisz.hr DOS/Admin · 5080 Zagreb Place · Washington, DC 20521-5080

Source: https://www.aisz.hr/phocadownload/forms/b-student-medical-history-form.pdf