Student Health Record Madrasah Zeenatul Quran UK

Details of Child

Child Name:*

Surname:*

Gender:

Male Female

Address:

Post Code:*

Home Tel No.:

Date of Birth:*

Language Spoken at home:

Child's Doctor's Name:

Doctor's Telephone Number:

Parents' Details

Father’s Forename:

Mobile No:

Mother’s Forename:*

Mobile No:*

With whom does your child live?

Both? Mother? Father? Guardian?

In case of emergency please provide contact name and no

Contact Name:*

Relation to Child, if any?:*

Tel No:*

Address:

PLEASE INFORM US ABOUT YOUR CHILD`S HEALTH CONDITIONS

My child has NO known health problem: Signature:*

Date

My child has the following known health problems:

Allergies - List any allergies to medications and describe the reaction::

Describe treatment:

Allergies - List any food and/or environmental allergies and describe the reaction:

Describe treatment:

Does your child wear glasses or contacts? :

Yes No

Does your child wear hearing aid?

Yes No

Does your child suffer with Asthma?

Yes No

If yes, which Inhaler does he/she takes and how many puffs?

List all medications that your child taking (include those prescribed by a health professional as well as any over-the-counter medications, vitamins and/or herbal supplements). Include name and dosage.:

History of serious illnesses and or injuries:

If your child needs any medications (inhaler etc..) during Madrasah time please send the prescribed medicine clearly labelled to Madrasah with clearly name & date on from the doctor or chemist. Please write below if you want to give more details or attach doctor`s letter.