Medical information form - Henley High School

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Student details

Student's name(Required)

First Last

Date of birth(Required)

DD slash MM slash YYYY

Gender(Required)

Female

Male

Other

Other(Required)

Address(Required)

Street address Address line 2 Suburb State Postcode Country

Phone(Required)

Email(Required)

Emergency contact details

Name(Required)

Prefix First Last

Address(Required)

Street address Address line 2 Suburb Postcode

Phone(Required)

Relationship to student(Required)

Healthcare details

Medicare number(Required)

Concession/Health Card number

Does the student have private health cover?(Required)

Yes

Private health fund name/number(Required)

Does the student have ambulance cover?(Required)

Yes

Ambulance cover fund number(Required)

Has the student been immunised for tetanus?(Required)

Yes

Date of tetanus immunisation(Required)

DD slash MM slash YYYY

Family doctor's name(Required)

First Last

Family doctor's phone(Required)

Does the student have any dietary requirements?(Required)

Yes

Please state the dietary requirements(Required)

Swimming ability: Can the student swim 50m?(Required)

Yes, but struggles

Yes, comfortably

Yes, strongly

Medical history

Does the student have, or have they had, any of the following

Select all that apply

Asthma

Allergy or reaction

Diabetes

Epilepsy

Asthma: A Medical Care Plan is required from your Family General Practitioner

If you don’t have this document available at this time, you must email it to [email protected] at your earliest opportunity.

Max. file size: 50 MB.

Allergy or reaction: Please provide details(Required)

Allergy or reaction: Please select the type of reaction(Required)

Local reaction

Systemic reaction

Anaphylactic reaction

Allergy or reaction: A Medical Care Plan is required from your Family General Practitioner

If you don’t have this document available at this time, you must email it to [email protected] at your earliest opportunity.

Max. file size: 50 MB.

Diabetes: A Medical Care Plan is required from your Family General Practitioner

If you don’t have this document available at this time, you must email it to [email protected] at your earliest opportunity.

Max. file size: 50 MB.

Epilepsy: A Medical Care Plan is required from your Family General Practitioner

If you don’t have this document available at this time, you must email it to [email protected] at your earliest opportunity.

Max. file size: 50 MB.

Does the student have, or have they had, any of the following

Select all that apply

Fainting spells or dizziness

Loss of consciousness

Concussion or head injury

Migraine headaches

Heart condition of any kind

Anaemia or haemophilia

Stomach trouble or ulcers

Skin disease

Appendicitis

Chronic or frequent cough

Breathing disorder

Sight difficulty/disorder

Hearing difficulty/disorder

Joint problems or dislocations

Arthritis or rheumatism

Phobias

Psychological condition

ADHD or similar

Travel sickness

Bed wetting

Any serious injury or hospitalisation in the past 12 months

Please provide details for each of the conditions that you selected in the previous question(Required)

Is the student currently taking any medication?(Required)

Yes

Please provide medication details(Required)

Declaration

Declaration(Required)

I declare that the information which I have provided on this form is complete and correct and I will notify the school if any changes occur prior to the trial commencing.

Declaration

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