2 March 2015 IMPORTANT: STUDENT MEDICAL & PARENT ADDRESS DETAILS UPDATE 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 us of any changes or updates to this information by completing the appropriate sections of the attached form and returning it to the Health Centre. An Asthma/Anaphylactic Action Plan has also 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 doctor (medical practitioner) and forward it to the Health Centre. Parent Address 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. Please click on Next Address and Previous Address to view the multiple address pages. To make changes, select Update Address Details, 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. If we do not receive any information from you by the start of Term 2 2015, we will assume that all health information for your daughter as well as your address details 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 Please insert NAME & YEAR details and any UPDATED INFORMATION ONLY and return to the Health Centre by end of Term 1, 2015. (All information collection from this form is covered by the School s Privacy Policy. This information will be held by the School Health Centre. Student Details Surname Given Names Year Level Date of Birth Ambulance Cover Yes No Medicare No. Number on card Expiry Date Private Health Fund Name Number Expiry Date Doctor s Name Dentist s Name Parent/Guardian Details Doctor s Telephone Dentist s Telephone Parents Names Address Postcode Telephone (Home) Mobile Telephone (Work) Occupation Emergency Contact (In cases where a parent is not contactable must be within 2 hours of Southport) Name 2 nd Phone Number Address Postcode Medical History Does your daughter suffer from any of the following conditions? Condition Yes / No 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 Page 1 of 4
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) Indicate year of immunisation Chicken Pox CP Measles ME Diphtheria, Tetanus DT Measles, Mumps, Rubella MR 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 Influenza IN Tuberculosis BCG Indicate year of immunisation Whooping Cough Please enter name and dates of country specific immunisations, i.e. Typhoid, Cholera, Small Pox etc. WC Has your daughter had any of the following: Please record any relevant details on a separate sheet of paper and attach to this form. 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. 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. (Please tick only if your daughter has previously been given this medication without any adverse reaction) 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 codeine) Dimetapp Elixir Declaration I hereby declare that the above information is an accurate record of my child s health, and that 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 changes 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. Page 2 of 4
Asthma/Anaphylaxis (Severe Allergy) Action Plan Please complete this form and return it to Student Reception. 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. Student Details Student s Surname First Name Date of Birth Year Teacher Does your child wear a Medical Alert Bracelet:? Emergency Contact (In cases where a parent is not contactable must be within 200 kms of Southport) Name of 1 st Person Name of 2nd Person Doctor s Information Doctor s Name Usual Asthma Management Plan Alternate Phone Number Alternate Phone Number Doctor s Telephone 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 Page 3 of 4
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