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Gsis.sc.kr2

Gyeonggi Suwon International School Entrance Health Form
School APID#______________
Student’s Name;
Date of Birth
Entering Grade

Permission for giving medication for minor complaints
Acetaminophen (Tylenol) (for minor aches, menstrual cramps or headache etc…)
Pepto Bismol ( for nausea, diarrhea, stomachache or heartburn etc…) I give permission for my child to be given medication at the nurse’s discretion.
Parent’s Signature_______________________________ Date_______________________________________
Permission for Emergency Treatment
In the event that I cannot be reached in an emergency, I give permission for my child to receive medical treatment,
including transport to the most accessible hospital, as deemed necessary by school authorities.
Parent’s Signature_______________________________ Date______________________________________
Health History
(To be completed and signed by parents/guardian and verified by healthcare provider)

Student’s name________________ Date of Birth_________________ Sex; male_____ female_____ Grade__________ ALLERGIES (Food, drug, insect, other)
MEDICATION (List all prescribed or taken on a regular basis)
Head Injury/Concussion/Passed out? Yes No Dizziness or chest pain with exercise? Yes No Bone/Joint problem/Injury/Scoliosis? Yes No
Information may be shared with appropriate personnel for health and educational purposes.
Parents/Guardian: Signature_________________________________________ Date_____________________________________
Immunization
(below this page to be completed by Healthcare provider or Physical doctor)
Student’s name__________________________ Date of Birth_______________Sex; male_________female________Grade__________ VACCINE/DOSE
or DTaP) Diphtheria and Tetanus(Pediatric DT or Health care provider verifying above immunization history must sign below.
Signature ____________________________________ Title ___________________________________________ Date ______________________________________
Alternative proof of immunity
Clinical diagnosis is acceptable if verified by physician.
Measles(Rubeola) ____________________ Mumps _____________________ Vericella ______________________ Physician’s Signature _______________________________
Month/Day/Year Month/Day/Year Month/Day/Year
Physical Examination
Student’s name______________________ Date of Birth____________________ Sex; male_________ female________ Grade__________
HIGHT_______________________ WEIGHT__________________________ BP______________________
TB SCREENING; TB SKIN TEST ________________________________ or CHEST X-RAY________________________________
LAB TESTS*recommended only Date
SYSTEM REVIEW
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, prostatic device, dental bridge,
false teeth, athletic support/cup
MENTAL HEALTH/OTHER Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel. Check title ; nurse___ teacher___ counselor___
Principal____
EMERGENCY ACTION needed while at school due to child’s health condition (e.g. seizures, asthma, insect sting, food, peanut allergy,
bleeding problem, diabetes, heart problem)?
Yes_______ No_______ If yes, please describe.
On the basis of the examination on this day, I approve this child’s participation in (If no or modified attach explanation.)
PHYSICAL EDUCATION Yes____ No_____ Modified___ INTERSCHOLASTIC SPORTS(for one year) Yes____ No____ Limited____
Physician
Printed name: Signature: Date:
Address: Phone:

Source: http://www.gsis.sc.kr/_uploads/docs/health_history_form_09-10_1.pdf