MEDICAL DOSSIER FORM

INDIAN EXCELLENT Pvt. SCHOOL, SHARJAH P.O. Box: 40194, Tel: 06 5249249, Fax: 06 5249349 E-Mail: [email protected], www.iessharjah.com (Affiliated to C.B.S.E Delhi & Approved by Ministry of Education, UAE) ACADEMIC YEAR 2018-2019 GR NO.___________________ MEDICAL DOSSIER Name of Child ___________________________________________________ Nationality ________________________ Sex:_________Date of Birth :_________________________ Date of Admission _____________ Grade/Sec___________ Address:___________________________Street:_____________________________City:_________________________ Please provide the following information to update your child’s School Health Record. As indicated by the Ministry of Health, this is a compulsory requirement. Please attach a photocopy of the original vaccination card. Vaccination Record (Please write dates known) BCG (at birth):____________________ st DPT/POLIO (OPV):_________________ 1 Booster:_______________________(1½ years) nd 2 Booster:_______________________(4 ½ years) rd 3 Booster:_______________________(10 years) HEPATITIS B st rd nd (HBV) 1 Dose:_______________________, 2 Dose:___________________________, 3 Dose:________________ MEASLES (9 Months):_________________________ st nd MMR 1 Dose:________________________ (15 Months), MMR 2 Dose:___________________________(6-12 years) HIB(i)_______________________, (ii)________________________________,(iii)_______________________________ Hepatitis A (i)___________________________, (ii)________________________________ TYPHOID:____________________________, CHICKEN POX:_________________________, RUBELLA:_______________ BLOOD GROUP:_________________________ ID CARD NO:___________________________________________ HEALTH CARD NO:__________________________________________

Date of Birth- Place of Birth- Nationality- Father’s Name Job Educational Level Work Tele Number Mother’s Name Job Educational Level Work Tele Number Address Street Area Post Box City Residence Tel Number Incase of emergency contact- Telephone- Mobile- Positive Cases (Chronic health problem( which the student is suffering from- 1) 2) 3) Medicine advised at emergency Special precautions for sports and food Allergy From 1)Medicine- 2)Food- 3)Others- Name of Parent :___________________________________________________________________________________ Tel Off:_____________________________ Res:_____________________________ Mobile :______________________ Signature of Parent School Nurse