Is your child on the BUPA School Medical Insurance Scheme?
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- Bernadette French
- 5 years ago
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1 Section1 Student Forenames: Students Personal Medical Record Last Name: Date of Birth: Parental Address: Place of Birth: Fathers Address if Different: Phone Number: Address: Phone Number: Address: Current GP Details Name and Address of Current GP: Medication and Allergy History: Does your child take any regular medication, prescribed or otherwise? (please list) Does your child have any known allergies? (please list) Is your child on the BUPA School Medical Insurance Scheme? Yes No If no and you are using your own Private Health Insurance company please give the following information. Company Name Membership Number Please give name in which the policy is held, if held in the family name who is the main policy holder?
2 Has your child ever suffered from or consulted a doctor about any of the following? a)any infectious disease, such as malaria or typhoid, but excluding ordinary childhood infections (i.e. chickenpox) b) Persistent cough, shortness of breath, asthma, hay fever, sinusitis, tuberculosis or any other disease or the respiratory system. c) Raised blood pressure, a heart murmur, or any other disease of the heart or circulation. d) Persistent indigestion or diarrhoea, appendicitis, hernia or any other disease of the abdomen. e) Any problems with the kidneys or genitor-urinary system, such as cystitis or problems with menstruation. f) Any disorder of the glands such as diabetes or a thyroid disorder. Yes No If YES please give details g) Anxiety, phobias, depression, medication with tranquillisers or treatment by a psychologist or psychiatrist. h) Is there a history of an eating disorder? i) Disorder of the eyes, ears or ears, or any neurological disorder such as recurrent headaches or migraines? j)has the applicant ever been hospitalised or had a general Anaesthetic? k) Does your child bed wet? l) Does your child sleep walk? i) Has your child had an eye Date of last test test? ii) Dental Care Date of last check up: iii) Orthodontic care Date of last treatment: iv) Has your child ever had a hearing test? If YES Pass / Fail
3 1) Please give full details of any past injury or disease of the spine, or other bones, joints, muscles or ligaments, in particular back pain, or any previous injuries related to dancing or exercise. It is in your best interest to give full details particularly of any recurrent injury so that the medical team can help you resolve the problem. 2) Has your child received any other medical advice, treatment, investigations or treatment in hospital or from a Doctor, or are you contemplating any such treatment, about any other condition not mentioned above. 3) Are there any immediate family members who have had or are suffering for any of the following (please circle): High Blood Pressure Asthma Diabetes Epilepsy Please indicate the applicants relationship to the family member: 4) To the best of your knowledge and belief is the applicant now in good health? If not, please give full particulars and any additional information that you feel that we should know.
4 Section 2 Consent for Medical Needs Yes No 1) I consent to my child being prescribed medication by the school doctor. 2) I consent to the school nurse administering appropriate Medication to my child. 3) I consent to a Houseparent when necessary and appropriate Administering medication to my child. 4) I consent to my child receiving first aid treatment from an Appropriately qualified member of staff. 5) I agree to authorise Elmhurst Medical Centre to approve such Medical treatment for my child as is deemed necessary in an emergency. Parent/Guardian Signature: Date:
5 Consent to the Administration of Medication. Please note that the administration of all medication at Elmhurst School is carefully monitored, if you have any concerns please contact the school Medical Centre Drug Name and use Consent Creams and Lotions Consent Paracetamol Tablet or liquid Given for mild pain and to reduce temperatures. Ibuprofen Tablet or liquid Anti Inflammatory, used of muscular pain and reducing temperatures. Will not be given to students with Asthma. Piriton Tablets or Liquid Antihistamine, helps to reduce allergic reactions, hay fever and skin rashes. Will not be given to students with Epilepsy. Clarityn Tablets Antihistamine, once a day treatment for hay fever. Strepsils Lozenges Relief for sore throats Lemsip Powder For treatment of colds. Will not be used with other paracetamol based drugs. Simple Linctus Liquid Relief for cough. Sudafed Tablets Reduces nasal congestion associated with colds and sinusitis. Dioralyte Powder Used for replacement of essential water and salts, for those with dehydration. Imodium Tablets Used to treat symptoms of diarrhoea. Joy Rides Tablets Used to help with motion sickness. Arnica Cream: Used to reduce bruises. Witch Hazel Lotion Used to reduce bruises. Benadryl Cream Used to treat skin rashes. E45 Cream For the treatment of dry skin. Vicks Vapo Rub. Used to ease symptoms of catarrh. Olbus Oil Used as an inhalation to ease the symptoms of catarrh. Deep Heat Rub Helps to easse muscular strains and sprains. Biofreeze Gel Helps to ease muscular strains and sprains. Fenbid 5% - Gel Ibuprofen based topical gel, used to treat muscular pain. Will not be given to students with Asthma. Sun Tan Lotion Where possible please provide your child with their own. After Sun Lotion Where possible please provide your child with their own. Parental Signature: Date: Print Name:
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