Student medical record form

STUDENT MEDICAL RECORD 2024-2025

To ensure your child receives comprehensive health care in the event of an illness or injury in school, or whilst participating in a school trip, please complete the following form. It's important that you answer every question fully. This information will be shared with the treating medical authorities present at the time. Thank you for helping us make our school a safe place for your child. The NAS Abu Dhabi Clinic Team
Student information
Student name*

First nameFamily name
Gender*
Year group*
Date of birth*

DayMonthYear
Date
Home address*

Area/building

Villa no./ apartment no.

CityEmirate

Additional details
Parent/guardian information
Parent 1 - name*

First nameFamily name
Parent 1 - phone number*
Please enter a valid phone number.
Parent 1 - email address*
example@example.com
Parent 2 - name*

First nameFamily name
Parent 2 - phone number*
Please enter a valid phone number.
Parent 2 - email address*
example@example.com
Emergency contact*

First nameFamily Name
Emergency contact - phone number*
Please enter a valid phone number.
Emergency contact - email address*
example@example.com
Student vaccination details

The Health Authority requires that the school maintains current information of each child’s immunisation history. Therefore, we require you to update them throughout their time in school.
Vaccine schedules differ from one country to another due to particular health concerns of each country. Please see the UAE schedule for your reference: Children's health - The Official Portal of the UAE Government
Please upload a copy of your child's current immunisation record*

Cancelof
I confirm that the attached photocopy is a true copy of my child’s immunisation record.

Note: All vaccination record and latest vaccines of the student should be submitted in English format only.
Signed by:*

Parent/guardian first nameParent/guardian family name
Signature*

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School health screening consent 2024-2025

The Abu Dhabi Department of Health mandates that all registered students are screened annually for health concerns. This screening includes height, weight, and body mass index. All results are recorded and transferred to the Abu Dhabi Department of Health. I hereby consent to my child being included in the mandated health screening as outlined above.
Signed by:*

Parent/guardian first nameParent/guardian family name
Signature*

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Student medical history
Does your child have any of the following medical conditions:*

Allergies (i.e. food, ☐ medication or animalChronic Respiratory Diseases such as AsthmaCardiac DiseaseDiabetes MellitusEpilepsy / SeizuresGastric Problems (i.e. travel sickness)Hearing ProblemsAutoimmune DiseaseSkin Conditions (i.e. eczema)Social / Behavioral / Emotional / Learning ConcernsThalassemia / G6PD / Sickle CellHaematological DisordersA condition that requires immunosuppressant medicationNone of the aboveOther
Please provide details of any condition selected above.*
Please note:

If your child takes regular medication - or in case of emergency medication - please contact the School Nurse at clinic@nasabudhabi.ae. A care plan should be completed for your child, with attached medical prescription from your doctor.

Please select below as appropriate*

	Yes	No
Does your child take medications on a regular basis?
Does your child have visual difficulties?
Is your child receiving current or ongoing treatment for any medical, surgical or psychological condition?
None of the above

Please provide details of any condition selected above.*
Consent for the administration of medications and emergency treatment

In the event that your child becomes unwell, or he/she has injured him/herself, it may be necessary to administer specific medication or undertake treatment. Please see below the list of the medications or solutions used at the school.
This is to authorise the school nurse or trip leader to administer the appropriate treatment for the various situations that may arise.
- I have read and understand the list of the medications or solutions used at the School.
- I consent to my child being given the above age-appropriate medications should it be considered necessary.
- In the event of an emergency, I consent for my child to be taken to a doctor or hospital for diagnosis and treatment.
Parent/guardian name*

First nameFamily name
Signature*

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STUDENT MEDICAL RECORD 2024-2025

Student information

Parent/guardian information

Student vaccination details

School health screening consent 2024-2025

Student medical history

Consent for the administration of medications and emergency treatment