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Student Medical Form

 
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Carbrook State School 
Student Medical Record
To be completed by parent/guardian of all students participating in excursion which involve an overnight stay or periods in excess of one day. 
1. STUDENT DETAILS
Name of student:           Date of Birth:
     
Excursion description:           Dates:  
             
2. MEDICAL CONDITION Please indicate below any known medical conditions relevant to the above named student. 
In those instances where there is "YES" response, please describe the nature of the
problem or provide a letter from your doctor.
MEDICAL CONDITIONS RESPONSE ADDITIONAL COMMENTS
Heart problems: Yes / No          
         
Blood pressure: Yes / No          
         
Respiratory problems   Yes / No          
        (other than Asthma):          
Asthma: Yes / No          
         
Epilepsy: Yes / No          
         
Operations: Yes / No          
         
Allergies: Yes / No          
         
Drug reactions: Yes / No          
         
Recent illness: Yes / No          
         
Phobias: Yes / No          
         
Bed Wetting: Yes / No          
         
Other e.g. Travel Sickness,  Yes / No          
   Special requirments-dietary:          
Date of most recent    Yes / No          
            Tetanus injection:          
3. MEDICAL PRACTITIONER:
Name of family doctor:            
           
Address:            
           
Telephone Number: (        )          
         
Appendix 1
To be confidentially stored until the student is 25 years of age.
Year document is to be destroyed _____________________ ( Year) 
MEDICATION INSTRUCTIONS FROM PRESCRIBING DOCTOR
These instructions are requested from the doctor to enable the school to maintain its "duty of care" 
when administering prescribed drugs to students without which treatment the student 
 would be unable to attend school.
Doctor:                  
Address:                  
                 
Phone:                  
I have prescribed the drug              
(name of drug)
for              
(name of student)
to treat the condition of               
(name of medical condition)
This drug needs to be administered             
(dose) (frequency/time)
Special arrangements are necessary to administer the drug or monitor the student after drug administration.
YES (     ) NO (     )
Provide details of special arrangements:
           
                   
                   
                   
                   
                   
                 
(Signature of Prescribing Doctor) (Date)
I agree to administration of medication as prescribed above.
                 
(Signature of Parent/Legal Guardian) (Date)
PLEASE NOTE:                
   
*     THAT MEDICATION THAT IS NOT PRESCRIBED BY A DOCTOR CAN NOT BE ADMINISTERED TO   
       STUDENTS WHILE ON CAMP. This includes any pain killers,cough mixtures etc.  
   
*     All medication MUST be in a container labelled by a pharmacist at the medical practitioner's direction,
        showing the name of the drug, the name of the student, the dosage, and the frequency of administration.
   
*     Medication not labelled correctly will not be accepted for use.   
       It is the responsibliity of the Parent/Carer  to ensure that the medication is clearly labelled,  
       is not out of date and is provided in sufficient  qualtities for the student's needs.  
   
*     Instructions solely from the parent/carer are NOT ACCEPTABLE.  
   
*     Your medical practitioner may fill in the accompanying form - Appendix 1 MEDICATION INSTRUCTIONS 
       FROM PRESCRIBING DOCTOR for over-the-counter medications such as panadol or cough mixture.
                   
5. DISCLAIMER
I hereby authorise the medical practitioner identified in Section 3 to provide to hospital authorities or other
qualified medical practitioner(s) additional information concerning any of the medical conditions
identified in Section 2 should such need arise.   
   
Signature of Parent /Guardian:             
   
Printed Name:           Date:    
                   
6. AUTHORITY
I hereby authorise the supervising teachers to obtain any medical or associated assistance which they deem
to necessary should any medical condition or accident occur.  
   
I agree to pay any ambulance, medical, dental and/or pharmaceutical expenses incurred on behalf of the 
above student which are not covered by my personal family ambulance subscription, medical benefits fund 
(or travel insurance in the case of overseas travel).  
   
I further authorise qualified practitioners to perform surgery, administer anaesthetic  and/or administer
blood transfusions if such an eventuality should arise.  
   
I understand that should such circumstances arise, the supervising teachers will endeavour to contact me
by phone in the first instance.  
   
Signature of Parent/Guardian:            
   
Printed Name:           Date:    
   
Phone Contacts:  Home:       Work:      
   
  Mobile:       Mobile: