學生醫(yī)療記錄StudentMedicalRecord

1、No.580, Gan Xi Road, Changning District, Shanghai, China 200335Tel: (8621) 6238-3511 Fax: (8621) 5218-0390 Website: HYPERLINK Email: HYPERLINK mailto:infoinfoPage PAGE 3 of NUMPAGES 3 Student Medical Form | 2014-15學生醫(yī)療記錄Student Medical Record請?zhí)顚懹么煮w字標注的表格。Please fill out in BLOCK CAPITALS.請用中文填寫好身體健康

2、表。Please fill out the medical form in English.學生姓名Student Name年級Grade性別Sex男Male 女 Female出生日期（月/日/年）Date of Birth (mm-dd-yy) 中國住址Address in China國籍Nationality出生地Birth Place血型 (請選擇一個)Blood Type (Please choose one) A AB B ORH因子RH Factor陽性POS 陰性ENG身高Height體重Weight個人歷史PERSONAL HISTORY請勾選出此學生是否接受過以下疾病的治療：

3、Please check if the student has received medical treatment for any of the following conditions: 注意力不足過動癥/注意力不集中ADD/ADHD哮喘Asthma背部問題Back Problems癌癥Cancer胸口疼Chest Pain水痘Chicken Pox肝炎Hepatitis閱讀障礙Dyslexia癲癇/突然發(fā)作疾病Epilepsy/Seizures頻發(fā)性中耳炎Frequent Otitis Media腰椎骨折Fractures Vertebra頻發(fā)性流感Frequent Colds頻發(fā)性頭疼

4、Frequent Headaches聽力問題Hearing Problems肺結(jié)核Tuberculosis單核血球增多癥Mononucleosis肺炎Pneumonia皮疹/皮膚問題Rash/Skin Trouble風濕熱Rheumatic Fever猩紅熱Scarlet Fever氣急氣喘Shortness of Breath視力問題Vision Problems出生缺陷Birth Defects精神病Mental Illness此學生現(xiàn)今是否定期服用藥物？Is the student currently taking medication regularly? 是YES 否NO如果是的話，

5、請詳細說明服用藥物是針對什么疾病的？If so, what medication and for what purpose? 此學生是否接受過手術(shù)？Has the student undergone surgery? 是Yes 否No如果是，請詳細說明：If so, please explain:此學生的家里任何成員有以下病癥嗎？如果有，請勾選：Has anyone in the students family suffered from any of the following conditions? If so please check: 糖尿病Diabetes 高血壓High Blood

6、 Pressure 心臟病Heart Disease 癌癥Cancer 精神病Mental Illness 癲癇/突然發(fā)作疾病Epilepsy/Seizures還有其他任何病癥嗎？Any other medical conditions?此學生有任何過敏嗎？Does the student suffer from allergies?藥物Drug(s) 是Yes 否No 環(huán)境因素Environmental factors 是Yes 否No 食物Food(s) 是Yes 否No 其他 (請詳細說明) Other (Please specify) 此學生與誰一同?。縒ith whom does t

7、he student reside? 雙親Both Parents 父親Father 母親Mother 監(jiān)護人Guardian此學生是否有任何的生理或者心理不適以至于不可以參加體育課？Does the student have any medical condition which would prevent him/her from participating fully in physical education classes? 是Yes 否No如果是，請詳細說明：If so, please explain:請注意，上海李文斯頓美國學校不接受有嚴重食物過敏的學生。Please be aw

8、are that LAS is not enrolling new students with any serious food allergies.疫苗記錄VACCINATION RECORD 1. 請勾選出您的孩子是否注射過以下疫苗。Please check if your child has received the following immunizations.2. 請附上注射以下疫苗的詳細報告以及注射日期。Please attach a copy of the following immunizations including dates of administration. 白喉

9、/百日咳/破傷風Diphtheria/Pertussis/Tetanus 麻疹/腮腺炎/風疹Measles/Mumps/Rubella 小兒麻痹癥 (口服/注射)Poliomyelitis (Oral/Inject) 乙型肝炎或者伽瑪球蛋白Hepatitis A or Gamma Globulin 乙型肝炎Hepatitis B 肺結(jié)核Tuberculosis 傷寒癥Typhoid 其他Others上一次的體檢日期（月-日-年）Date of last medical exam (mm-dd-yy)上一次的視力檢查（月-日-年）Date of last vision exam (mm-dd-y

10、y)上一次的牙科檢查（月-日-年）Date of last dental exam (mm-dd-yy)在家長聯(lián)系不到的緊急情況下，應與以下人員聯(lián)系：PERSON(S) TO NOTIFY IN AN EMERGENCY IF PARENTS CANNOT BE REACHED.鄰居/好友的姓名Name of Neighbor/Friend電話號碼Phone Number家庭醫(yī)生/醫(yī)療診所的名稱Family Doctor/Clinic Name電話號碼Phone Number*如果您由于什么原因而不在上海了，請將您缺席的日期以及您不在期間應與哪位聯(lián)系的姓名以及聯(lián)系方式及時告知您孩子的班主任老師

11、以免有任何緊急突發(fā)事件發(fā)生。* If you are out of town for any reason, please notify your childs teacher regarding the duration of your absence and the name and telephone number of a person to contact in case of an emergency involving your child.在校服藥MEDICINE AT SCHOOL如果您希望您的孩子在校期間定期服用藥物的話，請用中文寫下藥物名稱并告知學校的校醫(yī)。If you

12、wish to have medicine administered to your child by the school nurse you must provide the nurse in writing (in English): 藥物名稱：The name of the medicine 藥物用途：The purpose of the medicine 藥物服用劑量以及頻率：The dosage and frequency of administration. 學生不允許擅自自己服用任何藥物。藥物服用必須在校醫(yī)的診所內(nèi)，并在其監(jiān)督下完成。Students are not permi

13、tted to have drugs or medications on their person. All such administrations must take place in the nurses office under her supervision.保險信息 INSURANCE INFORMATION所有學生必須持有自己的醫(yī)療保險。在辦理入學之前，醫(yī)療保險是必須的并且在學生就讀于李文斯頓美國學校期間不斷更新。All students must have their own medical insurance. Medical insurance details are re

14、quired at the time of admission and must be kept up to date for the duration of a students enrollment at SLAS.醫(yī)療提供商姓名Medical Provider Name保險單號碼Insurance Policy Number如果有緊急情況或者事故發(fā)生，請告知您傾向于就醫(yī)的醫(yī)院：If emergency/accident arises, please specify preferred hospital(s)選擇1 Choice 1 選擇2 Choice 2如果有重大的醫(yī)療緊急事件發(fā)生，并

15、且需要及時就醫(yī)的情況，那么上海長寧區(qū)中心醫(yī)院將會是首選，其地址為：仙霞路1111號，電話： (8621) 62909911 1333 或者1337。在送往就一直前，我們一定會及時通知到家長以及監(jiān)護人。在這張表格上簽名也就是意味著您給予了上海李文斯頓美國學校一個權(quán)力，即若有任何緊急事件發(fā)生的情況下，校方可以及時聯(lián)系醫(yī)院將您的孩子送醫(yī)。In case of a severe injury or medical emergency at school requiring transfer to a medical facility, Shanghai Chang Ning Medical Cente

16、r, No. 1111 Xian Xia Rd, Tel: (8621) 62909911 1333 or 1337, will be used. Every effort will be made to contact parents/guardians prior to transport. By signing this form you give Livingston American School permission to contact a medical practitioner and/or transfer your child to a medical facility in case of an emergency. 還有什么有關(guān)身理的信息是校方需要知道的？Is there any other health information about which the school should be aware?我確保上述表格中所填寫的信息均真實有效。我明白并了解如果我提供任何虛假信息或者遺漏任何信息的話，此學生將會不被錄取。I certify that the information provided in this application