We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
You are on page 1/ 2
The Amertan Itemationa Schoo «Venn
Ssimannidorter Seve 47
A190 Verma Asia
1 +43140 520
1 043140 B 2
rfotenat | wewanet
MEDICAL FORM
MEDICAL HISTORY
ONE PER APPLICANT
‘Allnew students and retuming students entering Middte or High Schoo! must submit
‘completed Medical Forms A & 8 before (re-Jenrolling at AIS Vienna,
ee
a's? va. School Year
Students name
NEW STUDENT RETURNING STUDENT UPDATE
IMMUNIZATIONS
PLEASEFILL OUT AS COMPLETELY AS POSSIBLE. LIST DATES OF IMMUNZATIONS
Instead of fling out ths section manual, you may submit complete copies of immunization records
(eg. "imppass" or mmurizaton book in any language).
Immunization FIRST_[SECOND| THIRD | FOURTH | FIFTH
DPT or,
Diphtheria
Pertussis (whooping cough)
Tdap
MMR (Measies/Mumps/Rubela) or
‘Measles (Masern)
‘Mumps
Rubella (Rote)
Polio ((PVIOPV)
Hepatitis A
Hepaiits B
‘BCG.
Tick shot / Zecken Impfung (FSME)
H. influenza B (HiB)
Varicella (chickenpox vaccine)
Meningitis C.
MCV. (Meningitis ACW)
Meningitis B
HPV (Human Papiloma Vitis)
‘TB Test and Resut
Wb submk Co
(Bors «
ke capes q Leann at) Crd
Scanned with CamScanner ALLERGIES
Does you child have ary alerges? Yes [1] No a
‘How does your child react o alergy? (Rash, hives, rouble breathing, watery eyes, nose rebles)
COMMUNICABLE DISEASE HISTORY
PLEASE FILL OUT AS COMPLETELY AS POSSIBLE - LIST THE DATES OF EACH LLNESS
Chicken Pox! male we
‘German meastes (Rubela) hain A? ok
7-day measles (Ruben) (20ST
FW
thaw & uals
CURRENT HEALTH
We should know about diabetes, seizire disorders, depression, anxiety, asthma, regular medication. Please give us a full
‘explanation:
"MEDICATION PERMISSION
4 | give permission for my child tospcie the following non-prescription medications at school
ParacetamalTylendl
Ibuprofen
‘Antacid
Anthistamine
a | give perission for my child to be given Potassium locide tablets In case of nuclear emergency.
Signature of PARENTSIGUAROINL .. Farbane Unran/
Scanned with CamScanner
