MEDICAL DECLARATION FOR THE ACADEMIC YEAR 2022 - 2023

Ibrahim Mohamed Youssef AbdelRahman Sallam Y3

Student Name: _________________________________________________________________ Year level: __________________________

In order to ensure a healthy and safe environment, it is important that the school is aware of any medical conditions of your
child. Please complete this form:

Health Conditions Yes No Remarks

Diabetes
Heart Disease
High Blood Pressure (Hypertension)
CNS Condition ✔
Epilepsy ✔
Blood Disorder ✔
Anaemia
Haemophilia ✔
Any Allergy to Food, Medicine, Dust, Etc. ✔
Renal Problem ✔
Bone Disorder ✔
Asthma ✔
G6PD ✔
Hearing Difficulty ✔
Eye Sight Difficulty (Myopia, Hyperopia, Etc.) ✔
Learning Disability ✔
Any case that may weaken the immune system
such as cancer (Blood Cancer, Lymphoma) or ✔
transplants? Please specify.
Any previous hospitalization? Please mention
the cause if any. ✔
Any ongoing medical condition? (If you
answered yes, please supply details as a ✔
separate attached document to this form)
Any medication that your child is not allowed
to take? If yes, please specify on the remarks ✔
column.
Any other problem or disease not mentioned
above? Please specify if any.
✔

For medical condition identified above which requires prescribed medication during school hours, please provide written
verification from your child’s doctor with diagnosis, type of medication, dosage and time to be given. Kindly arrange a meeting
with the school doctor before your child starts school.

Student will be officially enrolled after this form has been submitted and reviewed by the school doctor.

✔ I give permission to the school’s clinic staff (nurse or doctor) to give “Adol” or “Panadol” to my child if the need arises.
✔ I give permission to the school’s clinic staff to share medical information about my child with other staff members when that
information is necessary for the medical well-being of my child.
✔ I give permission to the school doctor to provide treatment to my child in case of first aid or EMERGENCY.
✔ I accept that it is my responsibility as the parent/guardian of the above mentioned student to inform the school of any
changes in the medical or physical condition of my child at any time during the school year.

I hereby certify that the information I provided is complete and accurate.

Mohamed Youssef Abdelrahman Sallam Father
Full Name: ________________________________________________________________ Relationship to Child: _____________________________
06.12.2022
Signature: _________________________________________________________________ Date: ________________________________________________