Please administer the following tests:

Tuberculosis All grades □Skin test □Chest X-ray □IGRA test

Date MM/DD/YYYY Result ____ _____ _
(Chest X-ray is required if the TB skin test result is positive.)
27, Daewangpangyo-ro 385beon-gil, Bundang-gu, Seongnam-si , Gyeonggi-do, 13543 Blood test All grades Blood type A / B / O / AB Rh + /−
Tel:+82-31-789-0549, 0556 / Fax:+82-31-748-0509 [Link] ≥7th grade HBsAg □negative □positive
<Part A-2> PHYSICAL EXAMINATION CERTIFICATE ≥10th grade Hemoglobin g/dl
(TO BE COMPLETED BY MEDICAL DOCTOR) Urine test All grades □Normal □Abnormal finding ______________
(Date of Exam - within 6 months before entry to school)
Please check for evidence of the following required immunizations.

DTaP #1__ #2__ #3__ #4__ #5__ Td #1__

Student’s Name(Last, First, Middle) Date of Birth (mm/dd/yyyy) Gender Grade
IPV #1__ #2__ #3__ #4__ Hib #1__ #2__ #3__ #4__
*Color-blindness test≥for 4th grade.
MMR #1__ #2__ PCV #1__ #2__ #3__ #4__
Height_______ Weight BMI BP
HepB #1__ #2__ #3__ HepA #1__ #2__
Vision Screening Rt__________ Lt__________
Varicella #1__ #2__
Color-blindness test* □Within normal □Concern identified__________________ *HPV #1__ #2__ #3__ *JE #1__ #2__ #3__ #4__ #5__
Hearing Screening □Pass □Fail * Additionally recommended immunizations in Korea.(not required for admission)
Dental Assessment □Within normal □Problem identified: Referred for treatment I have verified that these immunizations have been administered.
Developmental Evaluation □Within normal □Concern identified__________________ Yes_______________ No________________

Please be strict on immunizations. Administer appropriate immunization to complete.

Physical Exam Normal Describe Abnormal
Summary of findings (check one):
Skin
□ Well child: no conditions identified of concern to school program/activities.
Nose and Throat
□ Conditions identified that are important to schooling or physical activity.
Heart
(please explain):
Lungs

Gastrointestinal

Genitourinary Print name of physician ____________________________________________________________

Neurological Signature of physician _____________________________________________________________

Musculoskeletal Name of Clinic/Hospital Date (mm/dd/yy) _______________________

 Korea International School (A)
<Part A-1> Health information form
(TO BE COMPLETED BY PARENT) *Please return completed form to the Nurse’s Office
Student’s Last First Middle Date of Birth Male ( )
Grade:
Name (mm/dd/yyyy) Female ( )
Mother’s Name (Last, First) Father’s Name (Last, First) Cell Phone Emergency Contact Information
Father: Name:
Home Address Relationship:
Mother: Phone:
HEALTH HISTORY
ALLERGIES □ No □ Yes (If yes, list specific allergy, reactions, and treatment) MEDICATION
□ Food: □ Medicine: Does your child take any medication on a regular basis? □ No □ Yes
□ Seasonal □ Other: □ Medication taken at school – Name of medication:
□ Medication taken at home – Name of medication:
HEALTH CONCERNS □ No □ Yes (If yes, please explain):
□ ADHD (Attention Deficit Hyperactivity Disorder) □ Asthma □ Autism □ Mental / Physical □ Diabetes
□ Heart □ Hearing □ Vision □ Surgery □ Other
Had Chickenpox disease? □ No □ Yes
REQUIRED IMMUNIZATIONS Please fill out the date or attach a copy of official immunizations report in English/Korean.
*JE, BCG and HPV are additionally recommended in Korea, not required for admission.
DTaP Hib MMR
HepB (Haemophilus influenza PCV IPV / OPV *HPV *JE
(Diphtheria, Tetanus, (Measles, Mumps,
(Hepatitis B) (Pneumococcus) (POLIO) (Human Papilloma Virus) (Japanese Encephalitis)
Pertussis) type b) Rubella)
① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY ① MM/DD/YYYY
② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY ② MM/DD/YYYY
③ MM/DD/YYYY ③ MM/DD/YYYY ③ MM/DD/YYYY ③ MM/DD/YYYY ③ MM/DD/YYYY HepA (Hepatitis A) ③ MM/DD/YYYY ③ MM/DD/YYYY
Var (Varicella) ④ MM/DD/YYYY ④ MM/DD/YYYY ④ MM/DD/YYYY ④ MM/DD/YYYY ① MM/DD/YYYY *BCG (Tuberculosis) ④ MM/DD/YYYY
① MM/DD/YYYY ⑤ MM/DD/YYYY Td/Tdap(11~12ryrs) ① MM/DD/YYYY ② MM/DD/YYYY ① MM/DD/YYYY ⑤ MM/DD/YYYY
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATION AT SCHOOL
Over-the-counter medication may be Antipyretic medicine □ Tylenol □ Advil (Ibuprofen) □ Tylenol cold
administered in the Nurse’s Office as
needed with permission of the student’s Digestant medicine □ Festal (Pepto-Bismol) □ Baekcho syrup (Herbal syrup) □ Buscopan (Antispasmodics) □ Smecta (Antidiarrheal)
parent. Please check each medication
for which you are giving permission. Allergy medicine □ Zyrtec □ Clarityne □ Cospen (Actifed)
______________________________ ______________________________ _______________________
Form last updated: May 2017 Print name of parent Signature of parent Date (mm/dd/yy)