6 February 2017 IMPORTANT: CURRENT STUDENT MEDICAL & PARENT ADDRESS DETAILS Dear Parents and Guardians STUDENT MEDICAL DETAILS The accuracy of the information you provide us in relation to your daughter s medical records is extremely important in ensuring the wellbeing of your daughter so she can be adequately cared for in times of illness, accident or medical emergency. Although every attempt will be made to contact the parent or guardian, there are times when medical personnel require current information immediately for the safety and appropriate treatment of your daughter. In the interest of your daughter s welfare, we ask that you: 1. Check your daughter s Student Health Records on Parent Lounge. 2. Advise of any changes or updates to this information by completing the appropriate sections of the attached form and returning it to the Health Centre. 3. An Asthma/Anaphylactic Action Plan has been attached for your convenience. If your daughter is an asthmatic and/or is required to carry an Epipen, and you have not already done so (or if there are changes to your daughter s management program), please complete this form in consultation with your daughter s (medical practitioner) and forward it to the Health Centre. PARENT CONTACT DETAILS Up-to-date Parent Contact details are essential for communication between home and School and ultimately for the wellbeing of your daughter. Please logon to Parent Lounge to check your contact details by clicking on Parent Details, followed by View Address Details. Click on Next Address and Previous Address to view the multiple address pages. To make changes, select Update Address Details to bring up the change screen, make the changes and then click on Submit Changes. Please note that it will take up to three business days for the changes to take effect. Please check there is an Emergency 3 rd Party contact listed for your daughter and that this is up to date this must be a person other than the parents. If we do not receive any information from you by the start of Term 2 2016, we will assume that all health information and contact details for your daughter on Parent Lounge are correct. Thank you for your assistance in updating this important information. Yours sincerely Ms Wendy Lauman Deputy Principal
STUDENT HEALTH RECORD B It is the responsibility of parents to ensure that the Student Health Information maintained by the School is accurate and that the School is informed of any changes to medical information which may affect the welfare and wellbeing of a student. All information collected from this form is covered by the School's Privacy Policy. It is important that you answer all questions. If the question does not apply to your daughter please write N/A (not applicable) in the space provided. Student Details Surname Given Names Expected to commence (ie Term 4, Year 8, 2016) Date of Birth Ambulance Cover Yes No Medicare No. Number on card Expiry Date Private Health Fund Name Number Expiry Date Parent/Guardian Details Parents Names Address Postcode Telephone (Home) Telephone (Work) Mobile Occupation Email/s Emergency Contact (In cases where a parent is not contactable please nominate a 3rd emergency contact (other than a parent) within 2 hours drive of Southport) Name Relationship Mobile Phone 2 nd Phone Number Address Postcode Current Medications Medication Dosage and Frequency Condition I give permission for the medication ticked below to be administered should my daughter suffer from a minor ache or pain. tick only if your daughter has previously been given this medication without any adverse reaction) (Please Paracetamol Ibuprofen eg: Nurofen I give permission for the cold and flu medication ticked below to be administered should my daughter suffer from cold and flu symptoms (please tick). Dimetapp Cold & Flu tablets Cold & Flu Relief tablets (contains Dimetapp Elixir
Medical History Does your daughter suffer from any of the following conditions? Condition Yes / No Provide accurate details of condition and treatment Allergies: (If the student is required to carry an EpiPen, please return the attached Anaphylactic Action Plan completed by your General Practitioner (GP) ). Asthma: (If YES, please return the attached Asthma Action Plan completed by your GP.) Diabetes Epilepsy Other Immunisation Details If born since 1996, please attach a copy of the student s Immunisation History Statement from the Australian Immunisation Register. This is available from any Medicare Office or by phoning 1800 653809 or through the Health Insurance Commission website (www.medicareaustralia.gov.au) Year of immunisation Chicken Pox CP Measles, Mumps, Rubella MR Year of immunisation Diphtheria, Tetanus, Whooping Cough [DTPa] TA Meningococcal C MC German Measles [Rubella] GM Pneumococcal Conjugate PC Haemophilus Influenza TypeB HIN Polio (inactivated poliomyelitis) P Hepatitis A HA Rotavirus R Hepatitis B HB Sabin Oral OPV Polio SO Human Papilloma Virus [Gardasil] HPV Tetanus (Booster) TT Whooping Cough WC Please enter name and dates of country specific immunisations, i.e. Typhoid, Tuberculosis, Cholera, Small Pox etc. Has your daughter been diagnosed with any of the following illnesses: Please provide relevant details separately. Chicken Pox Whooping Cough Measles Mumps Hepatitis B German Measles (Rubella) Glandular Fever Migraines Fractures (Please supply relevant details) Operations (Please supply relevant details) Please list any other disorders/diseases of which we should be aware Please list any dietary intolerances Are there any diet-related religious requirements?
ASTHMA/ANAPHALAXIS (SEVERE ALLERGY) ACTION PLAN Please complete the form overleaf and return it to the School. All information collected from this form is covered by the School's Privacy Policy. This information will be held by the School Health Centre. This record is to be completed by parents/carers in consultation with your child s Doctor. Usual Asthma Management Plan Child s Symptoms: Triggers (exercise, pollens) Medication Name Method of use (puffer and spacer, turbuhaler) When does the student require medication and how much? In an Emergency follow the Plan below that has been ticked Standard Asthma First Aid Plan Or Step 1 Sit the student upright, remain calm and provide reassurance. Do not leave student alone. Step 2 Give 4 puffs of a blue puffer (Airomir, Asmo, Epaq or ventolin), one puff at a time, preferably through a spacer device. Ask the student to take 4 breaths from the spacer after each puff. Step 3 Wait 4 minutes. Step 4 If there is little or no improvement, repeat steps 2 and 3. If there is little or no improvement, call an ambulance immediately (Dial 000). Continue to repeat steps 2 and 3 while waiting for the ambulance. *Use a blue reliever puffer on its own if no spacer is available. A Bricanyl Turbuhaler may be used in first aid treatment if a puffer and spacer are unavailable. My Child s First Aid Asthma Plan is attached: AUTHORISATION I authorise school staff to follow the preferred Asthma First Aid Plan or Allergy Action Plan and assist my child with taking medication should they require help, I will notify you in writing if there are any changes to these instructions. Please contact me if my child requires emergency treatment or if my child regularly has asthma symptoms at school. Parent Name Parent Signature Date I verify that I have read the preferred Asthma First Aid Plan and agree with its implementation. Doctor s Name Doctor s Signature Date Declaration I hereby declare that the above information is an accurate record of my child s health. I give St Hilda s School permission to administer medical treatment to my child. I understand that it is my responsibility to inform the School of any change to these details. Parent Name Parent Signature Date Each boarding student must have a medical examination before commencing school and a certificate produced to include any sporting restrictions, visual or hearing defects and minor problems. It is the responsibility of parents to ensure that all girls have adequate insurance to cover the cost of any medical, dental, ambulance or other related expenses that may arise. If you are not an Australian citizen and/or are not registered with Medicare you will need to obtain insurance as medical treatment in Australia is not free. Initial hospital treatment is generally provided by local Private Hospital.