Student Medical Examination Form

STUDENT MEDICAL EXAMINATION FORM

Niva International School

(Form AD-3)

18 Soi Pho Kaew Yaek 9, Klongchan, Bangkapi, Bangkok 10240 Thailand Tel# 02-9484607 ext 102

Entering grade: ____________Admission date: ______________Registration no. _______________

PLEASE PRINT LEGIBLY IN BLOCK LETTERS

Please attach a

recent photo

Name of Student (Last) __________________________________ (First) __________________________ Nick name:_____________

Gender/Sex:

Male

Female

Birth date: Day_______Mo________Yr_______ Nationality: _________________________

Parent’s Name: Father

(Last) ___________________________ (First) ______________________ (Middle) _____________________

Mother (Last) ___________________________ (First) ______________________ (Middle) _____________________

Home Address in Thailand: __________________________________________________________________________________________________________________

__________________________________________________________________________________________Home Tel: _____________________________________

Medical History:

1. Significant illness, accidents, operations, congenital defects, family history, etc. ______________________________________________________________________

2. Significant factors in home situation relating: well-being and academic performances __________________________________________________________________

To the private physician:

In order that the student’s program can be adjusted to his physical condition, and in order that sound health counseling can be given him, it is necessary

for the school to have a report of his health examination. This report will be held in confidence and used only for the protection and aid of the student in his education. Thank you.

3. Are there abnormalities of the following systems? If yes, describe fully. Use additional sheet if necessary.

a. Head , Ears, Nose, or Throat

Yes No

h. Height _____________Weight ____________ BMI _____________

b. Hearing

R _____L ______

Yes No

Any significant weight changes in the last year? ______________ Yes

No

c Eyes : Vision

R_____L_______

Yes No

i. Is there any serious physical defect?

Yes

No

d. Cardiovascular System

Yes No

j. Is the student now under treatment for any medical or emotional condition?

Blood Pressure _______mmHg

_____________________ __________________________________ Yes

No

Pulse Rate ________Respiratory Rate ________

k. Recommended for physical activity (Phys. Ed., Intramurals, etc.)

Unlimited

Limited Explain __________________________________

e. Gastrointestinal System

Yes No

l. Recommended class load and labor load

Restricted

Unrestricted

f. Genitourinary System

Yes No

m. Allergies: ________________________________________________________

g. Musculoskeletal System

Yes No

(Medication, food, and /or other)

h. Metabolic Endocrine System

Yes No

n. General Comments: ________________________________________________

4. These immunizations are required and must be completed in full and signed by physician before student can be accepted. An official record of

childhood and current immunizations must accompany school file. Please attach to this form.

5. Tuberculin skin test _____________________Chest X-Ray___________________

History of Immunizations

Day/ Month/ Year

BCG (TB Vaccine), if given

6. PLEASE CONDUCT THESE TESTS (if appropriate) AND ATTACH

INFORMATION ABOUT TESTS GIVEN AND THE RESULTS

No. 1 ______________________

Diptheria/

No. 2 ______________________

If there is evidence of the following

No. 3 ______________________

Pertussis/

Required

conditions please test for and attach

No. 4 ______________________

Tetanus

information

No. 5 ______________________

(DPT) or (DT)

No. 6 ______________________

Neuropsychiatric

YES NO

No. 1 ______________________

Learning Disabilities

YES

NO

No. 2 ______________________

Polio (OPV) and/or

No. 3 ______________________

IPV

Dyslexia

YES NO

No. 4 ______________________

No. 5 ______________________

Attention Deficit Disorder (ADHD)

YES NO

Measles (Rubella,

No. 1 ______________________

Hyperactivity

YES

NO

No. 2 ______________________

Rubeola -German)

Underachiever Characteristics

No. 1 ______________________

YES

NO

Mumps

No. 2 ______________________

No. 1 ______________________

Varicella (chicken pox)

No. 2 ______________________

Hospital

Physician’s Name & Signature

Hepatitis A ________________________________________

Stamp

B________________________________________

Japanese Encephalitis _______________________________

Date of Examination (Day/Month/Year)

_______________________________

I hereby certify that the above information is

Others: ___________________________________________

true and was tested to the best of my ability.

Medical Examination Form ( Ad-3),

revised (July 2, 2009) by NIVA Health and Hygiene Committee