StudentsName学生姓名 Date of Birth 生日 Sex 性别.docVIP

Students Name学生姓名 Date of Birth 生日 Sex 性别 Please check the immunizations your child has received and attach a copy of the child’s immunization record 家长请提供孩子的免疫记录，并请提供孩子最近的免疫记录附件： □ Measles 麻疹 □ Mumps腮腺炎 □ Rubella 风疹疫苗 □Typhoid伤寒 □ Hepatitis B B型肝炎 □ Pertussis (Whooping Cough)百日咳 □ Polio 麻痹症 □ TB 肺痨 □ Diphtheria /Tetanus 白喉/破伤风 Does your child have any of the following? 你孩子有下面的健康问题吗？ □ Heart Disease/心脏病 □ Head Injury/头部受伤 □ Epilepsy/羊痫风 □ Asthma/哮喘 □ Stomach problems/胃病 □ Diabetes/糖尿病 □ Skin Disease/皮肤病 □ Allergies/过敏 □ Eye/Ear Problems/眼睛或耳朵疾病 □ Menstrual Problems/月经问题 □ Tuberculosis/肺痨 □ Frequent headaches/经常头疼 □ Neurological Disorder/神经失调 □ Frequent nose bleeds 流鼻血 □ Psychological Disorders 智力/精神健康问题 □ Any Infectious Disease/任何传染性疾病 □ Other/其它 Please attach any relevant information or medical reports to explain any issues checked above or any other medical issues the school should be aware of. 请附加与上述有关的学生健康资料或值得学校注意的健康问题. Does your child take medication routinely? 有常规服用医药吗？ □ Yes/是 □ No/否 If yes, please explain 如有，请详列 (Please note, medications can only be taken at school when dispensed by the school nurse and with written permission of parents) 请注意：医药只能在学校服用，通过家长的写明同意。所有在学校服用的医药都从学校护士来提供. Does your child have any allergies? If yes, please list all allergies to foods or environment. 您的小孩是否对什么食物或环境过敏？ Does your child wear glasses or contact lenses?你孩子带眼镜或隐形眼镜吗？ □Yes/是 □No/否