Medical History Form

This is Section Two of the medical information the College requires about your daughter. Please complete the medical history form below.

Once you have completed this form, you will be redirected to the Co-curricular Questionnaire.

Section Two: Medical History Form.

Immunisation

1. Immunisation

  • An immunisation certificate is required for girls in Years K to 12 (inclusive)
  • A photocopy of the immunisation booklet is required for girls in Pre-K
  • If you have your daughter's immunisation record/certificate, please attached it below, otherwise a certificate of immunisation record can be obtained online at www.medicareaustralia.gov.au or by calling 1800 653 809.
Illnesses

Please list if your daughter has had any of the following illnesses, and if so, in what year:

  • Measles, Mumps, Rubella (German Measles), Chicken Pox, Hepatitis , Glandular Fever, Tuberculosis, Polio, Whooping Cough and others such as Malaria, Rheumatic Fever, Croup etc

Asthma

If you have ticked ‘yes’, please supply an ASTHMA ACTION PLAN. This can be obtained from your child’s GP.

If Yes, please answer the following questions below:

  • Has your daughter been to hospital due to asthma in the past two years? Yes / No 
  • Has your daughter been treated with oral cortisone in the past 12 months? Yes / No
  • Student’s current reliever is: 
  • Student’s current preventer is: 
  • Other medication taken for asthma.
Medical Information

The following questions are about your daughter's general medical health.

  1. Please answer Yes / No to the following medical conditions, including if your daughter suffers from any of the following: Diabetes. Epilepsy, Migraines, Fainting, Arthritis, Headaches, Attention Deficit Disorder, Menstruation, Menstrual Disorder and any other health issues of which the school should be aware? (e.g. special needs or disability, eating disorder, learning difficulties/problems, hepatitis B carrier, incontinence)
  2. Any counselling or psychological issues of which the school should be aware?
  3. Prescription medications. Please list prescription medications, the dosage and frequency that your daughter is currently taking
Anaphylaxis

The following questions are to do with whether or not your daughter has been diagnosed with Anaphylaxis. If yes:

  1. What are the triggering factors for your daughter’s anaphylaxis?
  2. Please attach a copy of the Anaphylaxis Treatment Plan as provided by your GP.
  3. Please provide a current adrenaline autoinjector and oral antihistamines (e.g. EpiPen or Anapen) for your daughter. This will be held in the College Health Centre.

Allergies

The following questions are to do with whether your daughter has been diagnosed with an allergy. If yes, please let us know if a doctor has diagnosed your child with an allergy to:

  1. Insect sting/bite (please specify)
  2. Any medications (please specify)
  3. Food(s) including: Peanuts, Nuts, Fish, Shellfish, Soy, Sesame, Wheat, Milk,  Egg and or any others
  4. Latex products

We also want to know if your child has been hospitalised with a severe allergic reaction or prescribed an adrenaline autoinjector (such as EpiPen or Anapen)

Declaration

By clicking on the submit button below, the parent/guardian of the student are indicating that:

  1. The information supplied is correct and a thorough summary of your daughter's medical history
  2. I/we hereby consent to the administration of medications specified in Section One and any others as notified by me/us, in writing as required and also provide the information as requested in Section Two of this form.
  3. I/we authorise you in the event of injury or illness of our daughter, to follow the procedure/s set out in Section One of this consent.
  4. I/we will undertake to inform you in writing of any changes to the information contained in this form as and when necessary. 
  5. This consent shall remain valid unless withdrawn by myself/us in writing to the school.
Mandatory field(s) marked with *