LYCEE FRANÇAIS DE SINGAPOUR Health Questionnaire 2013/2014

lfs.edu.sg

LYCEE FRANÇAIS DE SINGAPOUR Health Questionnaire 2013/2014

LYCEE FRANÇAIS DE SINGAPOUR3000 Ang Mo Kio Avenue 3 • Singapore 569928 • No. of Company :198004581HHealth Questionnaire 2013/2014 (confidential)For the students already attending the LFS during the previous yearsIF changes during the previous school year (2012/2013)Allergies : No Yes (please give details below)General Information :Surname:FIN:First Name:DOB: Medicine : Food : Other : Treatment : No Yes (please give details below)_____________________________________________________________________Sex: F M Class:_____________________________________________________________________Document to be filled IF changes during the previous year: Lunch box : Yes NoContinuation of the PAI : (Individual Care Plan)Tel (home):Mother’s HP:Mother’s work:Mother’s Email:Father’s HP:Father’s work:Father’s Email:Emergency Contact : (COMPULSORY and other than parents)Name :____________________ Tel :_______________________ HP :___________________Autorization for emergency care: In the event of an emergency situation where immediatecare and treatment are judged necessary by the school nurse/ management, I authorize theschool to have my child transported to the most appropriate medical services for his/hercondition. The school will take care of my child’s well-being first before contacting parents.Student’s passport number :_________________________________ Yes NoNew PAI : Yes NoNew treatments: Yes: which one:______________________________________________________________ NoHospitalization / Surgery Yes : motive : ______________________________________________________________ NoAny other troubles? Yes: which one:______________________________________________________________ NoOther:Vaccinations up to date : Yes NoDate: ______________Signature of parentsAdministration – Tel : (65) 6488 1160, Fax : (65) 6487 2821Ecole élémentaire – Tel : 6488 1192 • Vie scolaire – Tel : 6488 1168 • Service comptable – Tel : 6488 1173Site internet : www.lfs.edu.sg • E-mail : administration@lfs.edu.sg


I have noted the list (below) of medicines available at the LFS sick bay, and authorize the school nurse toadminister them if necessary:YES NOIn kindergarten and primary school only: In the secondary school (from 6 ème to Terminale) :• Panadol (paracetamol)• Spasfon Lyoc (abdominal pain)• Smecta (diarrhea)• Arnica granules (bumps and bruises)• Arnica pomade (bumps and bruises)• Eurax crème (insect bites)• Biafine emulsion (burns)• Chlorexidine (antiseptic solution)• Apis mell-belladona-kalium biochromicmercurius..(homoeopathyfor sorethroat)• Panadol (paracetamol)• Panadol menstrual• Spasfon Lyoc (abdominal pain)• Smecta (diarrhea)• Arnica granules (bumps and bruises)• Strepsil (sore throat)• Arnica pomade (bumps and bruises)• Eurax crème (insect bites)• Biafine emulsion (burns)• Chlorexidine (antiseptic solution)Comments:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date : Signature of parents :

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