MEDICAL FORM
The school has established a well-equipped infirmary (Wellness Centre) staffed with a
competent registered Nurse and a Counselling Psychologist.
The center’s objective is to provide basic emergency care, preventive, monitoring of
communicable/infectious diseases and psychosocial support during school hours.
Please complete and return this form as soon as possible.
STUDENTS HEALTH INFORMATION RECORD
Please note that it is assumed by the school that, where necessary, the parent has
sought the advice of the student’s physician prior to completing this form.
The responsibility lies with the parent/guardian to advise the school if any change
occurs in the medical or physical condition of the student at any time.
Student’s Name
Academic Stage (Year)
Date of Birth (mm/dd/yy)
Gender
MEDICAL INFORMATION
Allergy history and specific reaction
Yes No
If yes;
• Food(specify)
……………………………………………….………………………………......…
• Medicine(specify)
………………………………………………………………………………………
• Environmental (specify)
..………………………………………………………………………………………
Other allergies and description of their reaction
………………………………………………………………………………………………
………………………………………………………………………………………………
Is the child on medication? (If yes, indicate the medicine and dosage)
………………………………………………………………………………………………
………………………………………………………………………………………………
Please list below any hospitalization and operations that your child has undergone that
you consider have any bearing on their current health or well being
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….
Any chronic /congenital condition
Yes No
If yes, specify
……………………………………………………………………………………………………………….
Please give special instructions
……………………………….………………………………………………………………………………
……………………………………………………………………………………………………………….
Please give details of any other information concerning your child’s past or present
medical and/or dietary history, about which it would be useful for the school nurse to
be aware.
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Hearing Problems
Yes No
If yes, does the child use hearing aid Yes No
Vision problems
Yes No
Diagnosis: Short sighted Long sighted
Is your child currently receiving, or have they received in the past, counselling from a
psychiatrist, clinical psychologist or a counsellor? Yes No
If yes, please ensure you discuss this with the School Counsellor
MEDICATION INFORMATION
The school clinic stocks medication listed below to administer to your child if needed.
Please tick (√) the medication that we may administer to your child.
Antipyretics/analgesics Antihistamine Eye irritation
Paracetamol/acetaminophen Chlorpheniramine Normal saline flush
Yes (piriton) Yes
No Yes No
Ibuprofen No Diclone eye drops
Yes Cetirizine Yes
No Yes No
Sore throat No Probeta N. drops
Chlorhexidine/povidone iodine Abdominal Yes
gargle discomfort No
Yes Actal/Eno Insect bites
No tums/ulgicid Intamine cream
Strepsils Yes Yes
Yes No No
No Relcer gel Aqueous cream
Flu gone Yes Yes
Yes No No
No Hyoscine butyl
Zecuf Lozenges bromide
Yes Yes
No No
Soft tissue injuries Cyclopam
Diclofenac gel Yes
Yes No
No Eno
Deep heat spray Yes
Yes No
No Esomeprazole
Cold/hot packs Yes
Yes No
No Leporamide
Volini gel Yes
Yes No
No ORS
Deep freeze spray Yes
Yes No
No
Deep freeze gel
Yes
No
PARENT/GUARDIAN CONSENT FORM
I hereby irrevocably give consent for my child to participate in the School Health
Services Program. This includes: emergency care, health appraisal at school, monitoring
for communicable/infectious diseases and psychosocial support.
I am aware that in order for my child to receive any medication or medical attention at
school, I must fill and submit the attached medical form. Any supplementary
medication(s) must be brought to school by myself or a guardian.
In case of a serious accident or illness, I request the school to contact me. However, if
the school is unable to reach me, I hereby authorize the school to contact any one of
the contacts listed on the emergency and contact information list.
In the event that the emergency contacts cannot be reached, I acknowledge and
understand that the school may make the necessary arrangements to provide care
and treatment to my child. When necessary, and in the event that I, or any of the
emergency contacts cannot be reached, I hereby grant the school personnel my
permission to transport my child to the nearest emergency room. Under such
circumstances, I hereby authorize the school personnel to release the information
contained on this form to the emergency personnel and/or their authorized agent(s). I
accept that any costs associated with the administration of medical treatment shall be
borne by myself, as the child’s parent/guardian.
In case of an accident or illness where, in the reasonable judgement of the School
Health Personnel, no emergency treatment of my child is needed, but where she/ he is
unable to remain at school, I request the school to contact me to pick my child. If the
school is unable to contact me, I understand and agree that one of the emergency
contact persons, listed on the emergency and contacts information list, may be
contacted to pick my child.
I acknowledge that the school has trained its teachers on emergency care and as
such, in cases of an emergency or injury to my child, I understand that the teacher(s)
may be called in to assist the nurse if need be.
I also understand and agree that my child’s medical treatment records may be shared
with any appropriate persons, who require access to such treatment records, as shall
be deemed necessary by the school administration.
I understand and agree that it is my responsibility to promptly notify the school of any
changes in the information recorded on this form.
Emergency and contacts personnel list (when parent/guardian is unreachable)
1. Name …………………………………………..
Relationship………………………………….…
Mobile number…………………………………
Office number……………………….…………
2. Name ……………………………………….…..
Relationship………………………….…………
Mobile number……………….……………….
Office number……………….………………..
CONTACT DOCTOR (if applicable)
Doctor’s Name
……………………………………………………………………………..……………………
Mobile Number
…………………………………………………………………………………………………..
HOSPITALS OF CHOICE
The school has made arrangements with MP Shah Hospital, Village Medical Center and
Kenyatta University Teaching, Referral and Research Hospital, for emergency referral
cases.
In case your preferred medical facility is different from the ones stated above, please
indicate the preferred hospital for referral cases.
1. ……………………………………………………………………………………………
2. ……………………………………………………………………………………………
I certify that the information I have provided on this Medical Information Form is
accurate, true and correct.
I confirm that I have read, understood and agreed to the arrangements set out in this
Form.
Parent/Guardian:
Name: …………………………………………………
Signature: …………………………………………….
Date: …………………………………………………..
