Confidential Student Medical History & Consent Form Step 1 of 6 16% Confidentiality DisclaimerThe purpose of collecting the medical information outlined above is to enable Immaculate Heart College to provide for educational, social and medical wellbeing of the student. The information gathered enabled the College to carry out its legal obligation relating to the discharge of duty of care. Health information about students is sensitive information within the terms of the Australian Privacy Principles under the Privacy Act 1988 and the Privacy Agreement (Enhancing Privacy Protection) Act 2012. From time to time, the College may disclose personal and sensitive information to others for administrative, health and educational purposes. If you require access to your child’s personal information or you do not agree to personal information being obtained or shared to relevant organisations/medical practitioners, please contact the Principal in writing.STUDENT DETAILSStudent Name(Required) First Last Date of Birth(Required) Parent / Carer 1 Name(Required) First Last Parent / Carer 1 Email Parent / Carer 1 PhoneParent / Carer 1 Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Parent / Carer 2 Name First Last Parent / Carer 2 Email Parent / Carer 2 PhoneParent / Carer 2 Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Student lives with:Medicare Number(Required)Expiry Date (MM/YYYY)(Required)Position on Card(Required)Private Health FundMembership NumberPosition on CardDoctor (GP)PhoneDentistPhoneOrthodontist (if applicable)PhoneEmergency and/or carer's details if parents are unavailableName(Required) First Last Relationship(Required)Phone(Required)Name(Required) First Last Relationship(Required)Phone(Required)ACKNOWLEDGEMENT OF DISCLOSURE & EMERGENCY TREATMENT PROCEDUREWe acknowledge that the information contained in this completed Student Medical History & Consent Form provides full disclosure to the student’s medical, physical, learning and / or psychological needs.In addition, in the event of an emergency we acknowledge that:(Required) the College will attempt to contact the parents and nominated Emergency Contact Person the College will call an ambulance to take the student to hospital we give the College permission to approve emergency treatment we AGREE to emergency blood transfusion OR we DISAGREE to emergency blood transfusion Parent / Carer 1 Name Signature(Required) First Last Date(Required) Parent / Carer 2 Name Signature First Last Date PRESCRIPTION MEDICATIONPlease list any prescription medication that the student is currently taking, including dosage and frequency:MedicationDosageFrequencyMedicationDosageFrequencyMedicationDosageFrequencyMedicationDosageFrequencyAUTHORISED MEDICATIONParent/Carers are requested to inform the College of any medications being taken by students and of any changes to medication. All medications taken during the school day should be stored at the Health Centre unless other arrangements are made. All medications administered by the College will be recorded and will need a Medication Consent Form Completed.Non-Prescription or ‘Over-the-Counter’ Medications Paracetamol (eg. Panadol) as required Antihistamine (eg. Zyrtec, Claratyne, Telfast) Due to new Department of Health Regulations (Pharmaceutical Branch) no medication may be given to students unless authorised and supplied as stated above by parents. Paracetamol (Panadol) tablets will be held in the Health Centre should it be required by the students. Any other medications will need to be supplied to the Health Centre with the student’s name and instructions for use. If you authorise the College to administer over-the-counter Medications during the school day, please tick the relevant box above and sign in the space provided.Please list below any other non-prescription medications that the student may need and the name of the condition being treated. If the student requires these medications reasonably often (eg. migraine, allergy) please supply a small box of the medication to the Health Centre with the student’s name and instructions as to dosage and frequency.Medication:DosageFrequencyMedicationDosageFrequencyMedicationDosageFrequencyPlease sign by entering your full name(Required) First Last ALLERGIES AND TREATMENT REQUIREDDoes the student have allergies?(Required)Select oneYes (please complete items below)No (skip to the next page)Allergic to:Severe?Yes/NoYesNoAction Plan Attached?Select oneYesNoNot ApplicableAllergic to:Severe?Yes/NoYesNoAction Plan Attached?Select OneYesNoNot ApplicableAllergic to:Severe?Yes/NoYesNoAction Plan Attached?Select oneYesNoNot ApplicableHas the student been hospitalised with severe allergy?Yes/NoYesNoDoes the student have medication for the allergy?Select oneYes (please complete items below)NoPrescribed Medication MEDICAL ALERTAnaphylaxisDoes the student have Anaphylaxis?(Required)Select oneYes (detail below and attach the Action Plan)NoDetails of Anaphylaxis:AsthmaDoes the student have Asthma?(Required)Select oneYes (detail below and attach the Action Plan)NoStudent’s Current Reliver:Current Preventer:Other Medication/s Taken for Asthma:Has the student been hospitalised due to Asthma in the past 2 years?Yes/NoYesNoHas the student been treated with oral cortisone in the past 12 monthsYes/NoYesNoDoes the student have an Asthma Action Plan?Select oneYes (detail below and attach the Action Plan)NoDetails of Asthma:DiabetesDoes the student have Diabetes?(Required)Select OneYes (detail below and attach the Action Plan)NoDetails of Diabetes:EpilepsyDoes the student have Epilepsy?(Required)Select oneYes (detail below and attach the Action Plan)NoDetails of Epilepsy:Other Life Threatening ConditionDoes the student have a life threatening condition?(Required)Select oneYes (detail below and attach the Action Plan)NoDetails of Life Threatening Condition(s): MEDICAL CONDITIONSPlease list other conditions the College should be aware of(eg. Fainting, Hepatitis B Carrier, Incontinence, Special Needs or Disability, Learning Difficulties)FOOD INTOLERANCESPlease list any Food Intolerances(eg. Gluten, Wheat, Dairy, Lactose etc.)MEDICAL HISTORYHearing or Sight DifficultiesPlease advise if the students has any Hearing or Sight difficultiesBackground InformationIs the student undergoing counselling outside of school?(Required)Select oneYes (please indicate if you have provided the College with a psychological report)NoPsychological Report Submitted:Yes/NoYesNoNot ApplicableHas the student been diagnosed by a medical professional with (select all that apply): Anxiety ADHD Autism Depression OCD Other (please include details below) Details:Previous Childhood Diseases / InjuriesPlease list any previous childhood diseases / injuries the College should be made aware of:Previous OperationsPlease list any previous operations the College should be made aware of:Current TreatmentsPlease list current treatments the College should be made aware of: WATER SAFETYCan the student swim?(Required)Yes/NoYesNoAbility Level(Required)Select oneAdvancedIntermediateBeginnerNon-swimmerOTHERPlease list any other additional information the College needs to know about your child:
