Photo

NURSING SERVICES

Medical History Form

Dear Students:

Please ﬁll the data below, in case of any history of any disease. Please attach a photo.

Thanks.

Name:

________________________________ ID number:_____________

____Male____Female Age: _______ Mobile Number: _______________

Parent’s mobile number: ______________________

Any medications taken frequently? ___________

If yes, please write the Name________, the Dose of the medication_______

Please write the name of your medical insurance card ________________

and provide a photocopy attached to this form.

Signature: Nurse’s signature:

Photo

Yes / NO / /Medical case

Allergy

If yes, please write the name:

Bronchial Asthma

Nose Bleeding

Congenital Heart Disease

Diabetes Mellitus

If yes, please specify

type :

Diet controlled diabetic

Tablet controlled diabetic

Insulin controlled diabetic

Epilepsy

Anemia

Hypertension

Tuberculosis

Infective Hepatitis A,B,C

G6PD

)(

Thalassemia major

)(

Thalassemia minor

)

(

Surgical Operations

If yes, please specify which operation:

Other Diseases /

MEDICAL EXAMINATION FORM

Examiner: Complete this form which will serve as background for providing healthcare to the student. Please

print clearly as this form will be kept into the patient record by Khalifa University.

Blood pressure: Pulse: Height: Weight:

Application No.: Date:

Name: Date of birth:

Gender:

Test

Result

Remarks

Urinalysis

Chest X-ray

Complete Blood Count w/ Blood

typing

(attach results with interpretation)

Venereal Disease

Examination of AIDS

Hepatitis (All types)

Others:

Physical examination

Assessment

Remarks

SKIN

HEENT

I. Head

II. Eyes

I.1 Vision(Uncorrected/Corrected)

Left:

Right:

1.2 Distinguish colors

III. Ears

III.1 Hearing Acuity

IV. Nose

V. Throat

NECK

CARDIOVASCULAR

LUNGS

ABDOMINAL

Please list of any allergies including reaction:

Please list any current medications, medical device (implanted, embedded or attached to the body) and associated

problem:

Examiner’s comments/Overall Recommendations:

HEALTHCARE PROVIDER INFORMATION

Name:

Medical Facility:

Telephone & Fax Number:

Signature :

Stamp & Date:

GENITO-URINARY

MUSCULO-SKELETAL

NEUROLOGICAL

PSYCHOLOGICAL

The patient ___does ___does not have a history of emotional, psychological or psychiatric disorder,

including learning disability/ies. (If she/he does, please provide brief description)

NURSING SERVICES

Note: If you are 17 years-old and below, this form MUST be lled out and signed by your Parent or Legal Guardian.

If you are 18 years-old and above, you can ll-out and sign by your own.

CONSENT TO ADMINISTER NON PRESCRIBED MEDICATIONS

I authorize my child,

Name__________________________________________ Date of Birth_____________________________

Address_____________________________________________________________________________________

____________________________________________________________________________________

Phone Number________________________School Khalifa University

Class______________________________

be given the appropriate non-prescribed medication in the following cases:

1. Administration of Epinephrine in an acute allergic reacon (anaphylacc shock)

2. Administration of Salbutamol Inhaler to control asthmac symptoms

3. Administration of oral glucose for hypoglycemia

4. Administration of Paracetamol to control mild to moderate pain and fever

5. Other, please specify__________________________

Any precaution that the University personnel need to

know?

Any contraindication that University personnel need to

know?

What are possible reactions/side eﬀects?

What should be done in the event of reaction/side eﬀect?

Check appropriate boxes below:

I authorize designated university personnel to administer the above medication.

The above medication can only be administered by a HAAD Registered School Nurse.

1. I agree to hold the university and its employees harmless from any and all liability for the results of taking the

medicaon or the manner in which the medication is given.

2. I give my consent for University authorities to take appropriate action for the safety and welfare of my child.

Parent/Guardian (Full Name and signature) __________________________________

Date: ________________________