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_____________________________________
(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 SKIN TEST ________________________________ or CHEST X-RAY________________________________
LAB TESTS*recommended only Date
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___
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____

Printed name: Signature: Date:

Address: Phone:


Microsoft word - 54-temanni-jfim 2005.doc

Combinaison des données d’expressions génique et des données cliniques pour améliorer la qualité de la prédiction de la survie à 5 ans de patients atteints de cancer. Mohamed-Ramzi Temanni1, Blaise Hanczar1, Jean-Daniel Zucker1 1Laboratoire d’Informatique Médicale et Bioinformatique (LIM&BIO), UFR SMBH, Université Paris 13, France. Journées Francophones d�

Pay as low as $4 per month for each fill of brand-name PROTONIX (pantoprazole sodium)* This temporary card is activated and can be used to start saving right away! 1. Take your prescription for brand-name PROTONIX and PROTONIX Savings Card 2. Ask for brand-name PROTONIX. 3. Keep your card and use it to save on future PROTONIX prescriptions. Please note a permanent card shoul

© 2010-2018 Modern Medicine