SAIGON SOUTH INTERNATIONAL SCHOOL

78 Nguyen Duc Canh Street, Tan Phong Ward, District 7, Ho Chi Minh City, Vietnam
T: (84-8) 5 413 0901 - F: (84-8) 5 413 0902 - E: [email protected] - W: www.ssis.edu.vn

For office use only

HEALTH FORM Date:

This form must be completed and returned to the SSIS prior to school attendance.
All the information must be in English. Nurse’s signature

Name: Grade:
Last First Preferred name

D.O.B: (mm/dd/yyyy) Gender: Nationality

FAMILY INFORMATION:

Student resides with: Both Parents Mother Father Guardian

Mother / Name: Contact No.:
Father / Guardian Name: Contact No.:

If student will be staying with a guardian please provide contact information for the parents:
Parent Phone number: Parent E-mail:

EMERGENCY CONTACTS: Please do not list parents. These are numbers the school should call in the event that we
cannot reach the parent/guardian

Primary Contact Name: Secondary Contact Name:

Relationship: Relationship:
Phone number: Phone number:
Mobile: Mobile:

MEDICAL EMERGENCY AUTHORIZATION:

1. I authorize SSIS to refer my child to a hospital for urgent treatment in case the above emergency contacts
can not be reached. I shall bear financial responsibility for any such treatment.
2. Permission for minor medications: Ibuprofen (Advil, Ibudolol); Acetaminophen (Tylenol); Paracetamol (Panadol);
Antihistamine (Zyrtec, Clarityne); Antacid (Maalox, Gaviscon); Throat lozenges: YES NO

Parent ‘s name
in print: Parent ‘s signature:

Date: Month / Day / Year/

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2015-12-04
STUDENT HEALTH HISTORY

Student Name:
Last name First name Preferred name

Infectious disease history Health problems / issues / doctor ‘s diagnosis

NO YES (Give age) NO YES (Give age)
Rheumatic fever Vision problem
Chicken pox Hearing loss
German measles Seizure disorder
Measles Heart disease
Mumps Diabetes
Scarlet fever Orthopedic
Chronic ear infection Asthma
Urinary tract infection ADD / ADHD
Other(s) Other(s)

Serious illnesses / operations / injuries / disabilities (Please specify):

Medications taken regularly (include prescription and over the counter medications):
Medication Dosage Reason Frequency

Allergies (to food, medicine, insect stings or environment):

Health insurance informations:

Company name: Policy #

IMMUNIZATION HISTORY: Please review and transcribe dates of immunizations from immunization records
and include a copy of immunization book also.

Date of immunization (mm / dd / yy)

Vaccine
1st 2nd 3rd 4th 5th
Polio (OPV / IPV)
Diphtheria, Tetanus, Pertussis (DTP / DTaP)
Tetanus, diphtheria (Td)
Tetanus, diphtheria, pertussis (Tdap)
Measles, Mumps, Rubella (MMR)
Haemophilus influenza type b (Hib)
Hepatitis A
Hepatitis B
Varicella
Meningococcal A + C
Japanese Encephalitis
Typhoid
Human papilomavirus vaccine HPV
Other(s)

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Tuberculosis screening (For students from high incident regions): Please provide documentation for one of the
following:

BCG vaccine Given date (mm/dd/yy)

Tuberculosis Skin Test (TST) Date(mm/dd/yy) Result
Chest Xray if TST positive Date(mm/dd/yy) Result

PHYSICAL EXAMINATION (To be completed by a medical doctor)

Height Weight B.M.I percentile

Blood group Blood Pressure Heart rate

Vision acuity Right eye: Left eye:
Hearing acuity Right ear: Left ear:

Normal Abnormal Comments on abnormalities

Neurological
Cardiology
Respiratory
Musculo-skeletal system
Gastrointestinal
Integumentary
Urological
Attention Deficit Disorder
Endocrinology
E.N.T. (Ear - Nose - Throat)
Blood disorders
Other(s)

Special medical requirement at school (if any)

Recommendations for Physical

YES NO
Education activities
Competitive activities
Regular activities Please specify if NO:
Restricted activities Please specify if YES:

Date of examination: Physician’s name in print:

Month / Day / Year

Physician‘s address Physician’s signature

& Tel # & stamp

SSIS - Student Health Form | Page 3 of 4 |

GUIDANCE ON STUDENT HEALTH FORM.
The health form must be completed and returned the SSIS prior to school attendance. All the information must be
in English.

Recommended hospitals / clinics in Ho Chi Minh City: Your child can have the physical examination done at one
of the following hospitals / clinics:

1. Medical Family Practice: 34 Le Duan St., District 1 - Diamond Plaza building. Tel : 84 8 3822 7848
2. Columbia Asia International Clinic : 08 Alexandre De Rhodes St., District 1. Tel : 84 8 3823 8888
3. International SOS Clinic: 167 A Nam Ky Khoi Nghia St., District 03. Tel : 84 8 3829 8520
4. Victoria International Healthcare: Broadway D, 152 Nguyen Luong Bang, Tan Phu Ward, District 7.
Tel : 84 8 3910 4545
5 FV Hospital : 06 Nguyen Luong Bang, District 7, HCMC. Tel : 84 8 5411 3333

Immunization history: SSIS Immunization requirements base on CDC ‘s Immunization Schedule as below:

Vaccine 1st shot 2nd shot 3rd shot 4th shot 5th shot
Hepatitis B (Hep B) At birth 1 - 2 Months old 6 - 8 Months old
Diphtheris, Tetanus Pertussis (DTaP) 02 Months old 04 Months old 06 Months old 15 - 18 Months old 4 - 6 Years
Haemophillus influenza type B (Hib) 02 Months old 04 Months old 06 Months old
Pneumococcal (PCV) 02 Months old 04 Months old 06 Months old 15 - 18 Months old
Inactivated Poliovirus IPV 02 Months old 04 Months old 6 - 8 Months old 4 - 6 Years
Measles, Mumps, Rubella MMR 12 - 15 Months old 4 - 6 Years
Varicella (Chicken pox) 12 - 15 Months old 4 - 6 Years
Hepatitis (Hep A) 12 - 23 Months 6 Months after the
1st shot
Tetanus, diphtheria toxoids & Between 11 - 12 years old or between 13 - 18 years old
acellular pertussis (Tdap)

Tuberculosis screening:
For students from high incident regions - Please provide documentation of one of the following:
1. BCG vaccine.
2. Tuberculosis Skin Test (TST) results.
3. Chest Xray results if TST is positive.

Exemption from meeting the immunization requirement:

If a child is exempted from meeting the immunization requirement for medical reasons, a doctor ‘s written
statement is required. The statement must include:
1. Which immunization(s) is to be exempted.
2. The specific nature of the medical condition and probable duration of the medical condition.
3. Probable duration of the medical condition.

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