International School Bangkok Instructions for Completion of Returning Students Medical Package

Transcription

1 Instructions for Completion of Returning Students Medical Package All returning students must complete the returning students medical package unless a New Student Medical Package has been done in the preceeding 6 months. Please see the following attached forms which are in the medical package: 1. Physical Examination Report (Returning Student) 2018/19 This form must be completed by a licensed medical practitioner (does not need to be Thailand based). Students entering grades 3, 6, 9 and 11 need additional medical screening as outlined in this report. 2. Tuberculosis Screening Form (Returning Student) 2018/19 The upper part of this form is to be completed by the parents. If any of the potential symptoms of tuberculosis are present ( yes has been marked on the form) OR if the student is entering grades 3, 6 or 9 a tuberculosis screening test MUST be performed and the lower part of the form needs to be filled out by a licensed medical practitioner. 3. Nurse Medication and Emergency Treatment Consent Form 2018/19 This form must be filled out by one (or both parents) Please note: These forms should be submitted to the ISB Health Clinic no later that June Incomplete medical packages will not be accepted. ALL forms must be filled out and submitted at the same time. Forms can be delivered to the ISB Health Clinic or emiled to nurse@isb.ac.th If students have anaphylaxis, diabetes or asthma, 2018/19 Care Plans for these conditions MUST be submitted with the medical package. These forms are available from the ISB Health Clinic or the ISB website (under Health Services). If a student requires medication to be given on a regular basis a Prescription Medication Consent form must be filled out by the treating medical practitioner and the parents. This form is available from the ISB Health Clinic or the ISB website (under Health Services).

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3 Physical Examination Report (Returning Student) 2018/19 Please call or if you have any questions about this form. A qualified, licensed Medical Practitioner must complete THIS form. The examination should be completed and submitted by June 30 th 2018 to the ISB Health Center or send by to nurse@isb.ac.th. If the student has Diabetes, Asthma or Anaphylaxis, management plans for these conditions must also be completed (please see ISB website or nurse@isb.ac.th). Student Family Name: Given Names: Date of Birth: (dd/mm/yyyy) Gender M F Grade Level at ISB (2018/19) 1. Current Health Issues (include any current medications/allergies): 2. Health Assessment Weight: Units: lbs. or Kg Height: units: cm or feet/inches Pulse Blood Pressure / 3. Physical Examination Medical Appearance Normal Abnormal (referred for evaluation or treatment) Eyes, ears, nose, throat Lymph Nodes Lungs Heart (sound/murmur) Peripheral Pulses (nature) Abdomen Skin Musculoskeletal: Head & Neck Musculoskeletal: Back (to include scoliosis screening) Extremities (to include arms, legs, elbows, knees, hips and ankles) 4. Cardiac Evaluation Required for students entering Grades 6, 9 and 11 or if clinically indicated. ECG result (please attach a copy of the ECG): If ECG is Abnormal, please refer the student to a Pediatric Cardiologist for further evaluation and consultation (this may include Echocardiogram or Stress Test, for example). Please indicate any further follow up that is required. Page 1 of 4 Returning Students Medical Package (2018/19)

4 Student Last (Family) Name: Given Names: 5. Hearing Screening Required for students entering Grades 3, 6 and 9 Screened at 20dB: Right Indicate Pass (P) or Refer (R) in each box: Left Refer to Audiologist Permanent Hearing Loss Note: 6. Vision Screening Corrective lenses or glasses Yes No Distance Left Right Both 20/ 20/ 20/ Pass Refer to an eye doctor Note: 7. Immunization Review Please review immunizations and ensure all age appropriate immunizations have been given (unless contraindicated). Please note any immunizations given over the past 12 months (include date given): 8. Summary of Findings (check one) Well child; no conditions of concern have been found or identified. The child is cleared to participate in sports, athletics and school activities. Condition identified and the child is not cleared to participate in school sports, athletics and activities (please explain here including any restrictions and follow up required): 9. Certification Signature of Medical Provider: Name of Medical Provider: Date: Official Stamp: Qualifications: Page 2 of 4 Returning Students Medical Package (2018/19)

5 Tuberculosis Screening Form (Returning Student) 2018/19 Student Family Name: Date of Birth (dd/mm/yyyy): Given Names: Grade Level at ISB (2018/19): Tuberculosis Symptom Screen: Does the student have: Yes No Cough for more than 3 weeks? Blood stained sputum? Unexplained weight loss? Night sweats and fevers? Signed (Parent): Date (dd/mm/yyyy): Name: If Yes to any of the above OR for students entering Grade 3, 6 and 9, a Tuberculosis screening test is REQUIRED unless a screening test has been negative in the last 12 months (result must be submitted to the Health Clinic). The screening test done should be discussed with your Medical Practitioner to determine the most appropriate screening test for the student. ONE of the following tests must be done: OR OR Mantoux Skin test Positive Negative Date (dd/mm/yy): Induration in mm: Tuberculosis QuantiFERON test Positive Negative Date (dd/mm/yy): Chest X-ray Positive Negative Date (dd/mm/yy): Result: If the screening test is positive or suggestive of Tuberculosis, the student must see and Infectious Diseases Physician and provide a medical certificate stating they do not have active Tuberculosis and are not contagious to others. Please also indicate if they have commenced treatment for Tuberculosis. CERTIFICATION (ONLY required if screening test performed. Please do not certify until results are available) I certify that the above named student does not have evidence of active Tuberculosis (on screening test) and should not be contagious to others. Signature of Medical Practitioner: Date (dd/mm/yyyy): Name of Medical Practitioner: Qualifications: Official Stamp: Page 3 of 4 Returning Students Medical Package (2018/19)

6 Nurse Medication and Emergency Treatment Consent Form 2018/19 **Parents to complete this form** Student Family Name: Given Names: Date of Birth (dd/mm/yyyy): Grade Level at ISB (2018/19): The School Health Clinic provides some over the counter medications that your child may benefit from for certain presentations to the clinic. We will only provide these medications with parental consent. Please indicate whether you give consent for the nurse to administer the following: Medication: Use Yes No Telephone Parent Acetaminophen/Paracetamol Ibuprofen Decongestant (like Dimetapp) Antacid (like Tums) Antihistamine Pain, fever Pain, fever Nasal and sinus congestion Stomach upset Allergy I/We consent for the above named student to be given over the counter medications as outlined above. I/We undertake that I/we have given ISB authority to administer this medication on my behalf and accept full responsibility for the same in the event that my child has any adverse reaction to this medication, provided that the medication was administered in accordance with the instructions on the packaging. I/We give consent for emergency medical care to be provided to my child (on campus and during off campus ISB activities) with the understanding that I/we will be contacted as soon as possible. (Only one parent is required to sign; both may sign if you prefer.) Signed (Parent): Name: Telephone Number: Date (dd/mm/yyyy): Signed (Parent): Name: Telephone Number: Date (dd/mm/yyyy): Page 4 of 4 Returning Students Medical Package (2018/19)