M EDICAL HEALTH FO RM

Please complete this health information form and return it to the school nurse by the first day of classes.
The information provided will remain confidential by all staff.

Name of Student:

Grade:

Nationality:

Date of Birth:(d/m/y)

Residence number:

Mothers mobile:

Fathers mobile:

Alternative number:

Gender:
Male (M)

Female (F)

Has your child had any of the following? If yes, please specify the dates.
INFECTIOUS DISEASE
Diphtheria
Dysentery
Infective Hepatitis
Measles
Mumps
Poliomyelitis

YES

NO

Rubella
Scarlet Fever
Tuberculosis
Whooping Cough
Chicken Pox
Other

NON-INFECTIOUS DISEASE
Allergies, specify:
Bronchial Asthma
Congenital Heart Disease
Diabetes Mellitus
Epilepsy
G6PD(Glucose 6 Phosphate Dehydrogenase
deficiency)
Rheumatic Fever
Thalassemia (blood disorder)
Frequent headaches
Vision problems
Hearing Problems
Nocturnal Enuresis
Other

If you answered YES to any questions above, please add details below.

Family History:
Diabetes Hypertension

Stroke

Tuberculosis

Does your child have any visual disability? Yes

No

Other, specify: ______________

If yes, please specify:

Does your child have any special educational needs? Yes

No If yes, please specify:

YES

NO

Name of student:

Grade:

M/F

Consent for M edication

If your child is unable to take certain medications, please contact the school nurse to discuss the use of an alternative medication.
Yes

No

The school has permission to give my child over-the-counter medicines should it be

considered necessary by the school nurse. These medicines will only be administered
following careful deliberation.

Emergency Treatment
The school nurse will attempt to contact you should an emergency arise. In the event parents cannot be contacted, I authorize and
empower the School Nurse or a School Administrator to make any and all decisions concerning the medical and/or surgical care of my
child, which may include taking the child to a doctor or hospital for emergency treatment.
Yes

No

School M edicals
The UAE Department of Health and Medical Services requires that all students in both private and public school entering Pre-K,
Kindergarten and Grades 1, 5, 9 and 12, as well as all new students must have a clear Medical Health examination filed in the GWA
Medical Centre. This examination may be undertaken by the doctor of your choice. School medicals will be conducted throughout the
year by our licensed school doctor.
Yes

No

I consent to my child having a school medical, conducted by the school doctor, if in the above
specified grades or upon school entry.

Yes

No

I will arrange my own private medical appointment by a registered physician and will submit
the required report to the GWA Medical Centre within timelines required.

Parents Name and Signature: _______________________________

Telephone/Mobile Number: ________________________________

CONSENT FOR IMMUNIZATION

Childs Name:__________________________________

Class/Grade: ________

Date of Birth: _________________

School Name: GEMS World Academy
Do you wish your child to be vaccinated in the school? Please check the box for your answer.
I give the consent for the immunization of my child.
I dont agree for immunization of my child in the school.
Parents Name and Signature: _______________________________
Telephone/Mobile Number: ________________________________