Download the Kindergarten Health and physical examination record
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HEALTH AND PHYSICAL EXAMINATION RECORD
入园健康记录表
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Student’s Name/姓名：________________________________________________________
Family Name/姓 First Name/名 Middle Name |
Date of Birth 生日 ________ /________ /________ Telephone 家庭电话: _______________
mm/月 dd /日 yyyy /年 |
| Beijing Address 北京地址: __________________________________________________ |
| E-mail Address 电邮:________________________________________________________ |
| EMERGENCY CONTACT 紧急联络 |
Who should be notified in an emergency 有紧急状况应通知谁?
Father 父亲 Tel 电话: ___________________________ Mobile 手机: ___________________________
Mother 母亲 Tel 电话: ___________________________ Mobile 手机: ___________________________
Person to notify in an emergency if parents cannot be contacted 父母以外的紧急联络人信息:
Name 姓名: __________________________ Relationship 与学生关系: __________________________
Contact Tel 联络电话: ___________________________ Mobile 手机: ___________________________
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| MEDICATIONS AND CONDITIONS 健康条件 |
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lease describe any medical conditions (Allergies, Asthma, Heart disease，Epilepsy.) of your child that KinStar should be aware of 请指出您孩子需特别关心的健康状况 (过敏，哮喘，心脏病，癫痫...):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Does your child need to take any medication on a regular basis for any of the above? If so, please list in full detail 您的孩子是否因上述的健康状况而需要接受任何日常用药？ 如果是，请列出全部的细节:
__________________________________________________________________________________
Special food circumstances 特别的进食条件: _______________________________________
Family Doctor/Hospital or Clinic 家庭医生/医疗诊所: ______________________________
Address & Tel 地址及电话: ________________________________________________________
In case of emergency, we will transport your child to the nearest or most appropriate hospital or clinic. Please sign here if this is acceptable 遇有紧急状况发生时, 我们会将您的孩子送至最近或者最合适的医疗诊所就医。如果同意请签名:
______________________________ |
| IMMUNIZATION 预防疫苗 |
Has your child received any vaccination for 您的孩子注射过何种疫苗？
□ Tuberculosis 肺结核
□ MMR 麻疹，腮腺炎，风疹
□ DPT 白喉， 破伤风
□ Polio 小儿麻痹症
□ Hepatitis B 乙肝
Other 其他 _______________________________________________________________
Please bring record to be copied 请附上接种疫苗的记录影印本 |
Download the Elementary Health and physical examination record
HEALTH AND PHYSICAL EXAMINATION RECORD
入学健康记录表
|
Student’s Name/姓名：________________________________________________________
Family Name/姓 First Name/名 Middle Name |
Date of Birth 生日 ________ /________ /________
mm/月 dd /日 yyyy /年 |
Sex/性别: _______________ |
| Telephone 家庭电话: ___________________ |
Mobile/手机: _______________ |
| Beijing Address 北京地址: __________________________________________________ |
| E-mail Address 电邮:________________________________________________________ |
| EMERGENCY CONTACT 紧急联络 |
Who should be notified in an emergency 有紧急状况应通知谁?
Father 父亲 Tel 电话: ___________________________ Mobile 手机: ___________________________
Mother 母亲 Tel 电话: ___________________________ Mobile 手机: ___________________________
Person to notify in an emergency if parents cannot be contacted 父母以外的紧急联络人信息:
Name 姓名: __________________________ Relationship 与学生关系: __________________________
Contact Tel 联络电话: ___________________________ Mobile 手机: ___________________________
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| MEDICATIONS AND CONDITIONS 健康条件 |
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Hospital/Family Doctor (in Beijing)/固定医院或家庭医生: ___________________________
Address/地址: ______________________ Telephone/联系电话: ______________________
Please describe any medical conditions (Allergies, Asthma, Heart disease, Epilepsies) of your child that KinStar should be aware of 请指出您孩子需特别关心的健康状况 (过敏，哮喘，心脏病，癫痫...):
__________________________________________________________________________________
Does your child need to take any medication on a regular basis for any of the above? If so, please list in full detail 您的孩子是否因上述的健康状况而需要接受任何日常用药？ 如果是，请列出全部的细节:
_________________________________________________________________________________
Does your child have any allergies/请问您的孩子有过敏症状吗?
_________________________________________________________________________________
Please list all allergies, special food conditions /请列出所有过敏物, 特别的进食条件:
_________________________________________________________________________________
Does your child have any special dietary requirements/您的孩子有何特殊的饮食要求?
______________________________________________________________________________
Does your child have any physical disabilities/请问您的孩子有无任何身体上的障碍?
________________________________________________________________________________
In case of emergency, we will transport your child to the nearest or most appropriate hospital or clinic. Please sign here if this is acceptable 遇有紧急状况发生时, 我们会将您的孩子送至最近或者最合适的医疗诊所就医。如果同意请签名:
_________________________________________________________________________________
In the event of an emergency, do you agree to allow your child to have first-aid treatment at school (general first-aid treatment including minor cuts and abrasions)?
您是否同意如有紧急情况子女可在学校接受急救治疗（一般急救包括小伤口及擦伤）?
__________________________________________________________________________________
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| IMMUNIZATION 预防疫苗 |
Has your child received any vaccination for 您的孩子接种过何种疫苗?
Tuberculosis 肺结核 MMR 麻疹，腮腺炎，风疹 DPT 白喉， 破伤风
Polio 小儿麻痹症 Hepatitis B 乙肝
Other 其他 ________________________________________________________
Please bring record to be copied 请附上接种疫苗的记录影印本
Please note:
1. The school teacher will administer first aid to students, but will not prescribe any oral medication/学校仅给予急救事故处理,不配给口服药。
2. If your child needs to take medicine at school, please send it to the school office, labelled and with the correct dosage clearly stated/ 如您的孩子需要在学校服用从家里带来的药,请写清楚学生姓名,正确剂量等,并将药送到学校办公室。
3. If the student is not capable of participation in P.E. lessons or any other type of school activity, please specify, and submit a medical certificate for school reference/ 当您认为学生不宜上体育课或参加其他类型的学校活动，请具体说明,并提交医生证明供校方参考。
4. Any other remarks/其他补充信息__________________________________________________________________________________ |
_________________ (Parent’s signature 家长签名) _________________ (Date 日期) |
