Form 12-2006  2/2 To be filled out by the child’s parents.  3 copies: one copy to Host School to forward to the host family, one copy for accompanying adult, one copy kept by school.

INTERNATIONAL SCHOOL-TO-SCHOOL EXPERIENCE (ISSE)

VISITING CHILD’S HEALTH FORM

 

Name         ______________________________________________________________________________

Family Name                                                  Personal Name                                    Initial

Guardian 1 ______________________________________________________________________________

Family Name                                                  Personal Name                                    Initial

Guardian 2 ______________________________________________________________________________

Family Name                                                  Personal Name                                    Initial

Birth date (MM/DD/YY) ________________    Age __________       Sex: M _______ F _______

 

Home Address _______________________________________________________________________________________________

Telephone (Cell) ____________________________________________ (Work) ___________________________________________

School Name ________________________________________________________

In case of emergency, contact____________________________________ Relationship to child ______________________________

Cell of emergency contact  ___________________________________________ 

Past illnesses/diseases (Please give approximate dates.  Circle if current.)

_______ Colds                     

_______ Ear Problems                       

_______ Whooping cough            

_______ Hepatitis

_______ Bronchitis             

_______ Stomach disorders              

_______ Scarlet Fever                    

_______ Mumps

_______ Epilepsy                

_______ Heart troubles                      

_______ Athlete’s Foot                  

_______ Measles

_______ Sore throat           

_______ Convulsions                

_______ Motion Sickness              

_______ Asthma                 

_______ Chickenpox                

_______ Kidney Trouble               

_______ Rheumatic Fever

_______ Sinus                     

_______ Tuberculosis              

 _______ Ivy/oak poisoning               

_______ Migraines      

 _______ Diabetes                       

_______ German measles        

_______ Allergies

_______ Reaction to drugs (List)

_______ Operations/serious injuries (List)

Child’s normal body temperature ___________C/_______________F

 

Immunization test (Record dates of last injection)

_______ Diphtheria           

_______ Tetanus toxoid        

_______ Whooping cough

_______ Smallpox

_______ Tuberculin

_______ Typhoid

_______ Horse Serum Injection

_______ Schick

 

Polio vaccine: 1st dose _______                           2nd dose _______                                        3rd dose _______

 

Has there been a recent exposure to a contagious disease? _______ If so, what?

Is there a problem with...   sleep walking? ____    bed wetting? ____        constipation? ____       fainting? ____

 

Does this child have any restrictions in… swimming? _______      diving? _______        medical regime? _______ dietary regime? _______

If so, what?

Are there any activities that should be encouraged?____________________________________________________

Are there any activities that should be restricted?______________________________________________________

 

Is the child on any medication? _______ If so, please specify _________________________________________

Was this medication prescribed by a Medical Doctor? _______ Yes           _______ No

 

Are there any phobias        _______ Yes        _______ No      Explain ____________________________________________

 

Suggestions from parents? ___________________________________________________________________________

_________________________________________________________________________________________________

 

Insurance Company ________________________ Policy Number _________ In whose name?_________________

 

 

Date ____________________             

Parent signature __________________________________________________