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  • Health Check Up Consent Form

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    whereisgokul
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    The document is a health checkup consent form for a student of Bhavan's Vidya Mandir school in Eroor. It requests information from the student's parents on the student's medical history, including any recurrent illnesses, allergies, serious illnesses or surgeries, memory or concentration issues, current medications, history of COVID-19, and illnesses in family members. The parents are asked to provide details on these topics and sign the form to consent to the student's health checkup.

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    Health Check Up Consent Form (1)

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    The document is a health checkup consent form for a student of Bhavan's Vidya Mandir school in Eroor. It requests information from the student's parents on the student's medical history, including any recurrent illnesses, allergies, serious illnesses or surgeries, memory or concentration issues, current medications, history of COVID-19, and illnesses in family members. The parents are asked to provide details on these topics and sign the form to consent to the student's health checkup.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views1 page

    Health Check Up Consent Form

    Uploaded by

    whereisgokul
    The document is a health checkup consent form for a student of Bhavan's Vidya Mandir school in Eroor. It requests information from the student's parents on the student's medical history, including any recurrent illnesses, allergies, serious illnesses or surgeries, memory or concentration issues, current medications, history of COVID-19, and illnesses in family members. The parents are asked to provide details on these topics and sign the form to consent to the student's health checkup.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    BHAVAN’S VIDYA MANDIR, EROOR

    HEALTH CHECK UP CONSENT FORM

    NAME OF THE STUDENT …………………………………………………………………

    CLASS AND DIVISION ………………………………………………………………………

    1.Is there any incidence of recurrent fever and illness like cold, cough, throat infection, asthma etc.?
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ………………………………..…………………………………………………………………………………………………………………………………

    2.Is there any history of allergy to dust; food or medicine to student?

    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………

    3.Is there history of any serious illness or surgery to student?

    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………..……………

    4.Is there any problem with memory or concentration to student?

    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………..……………………

    5.Current intake of medication any taking by student?

    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………..…………………………………………

    6.History of any COVID illness/attack?

    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………

    7.History of any illness in family members like Diabetes, Heart Disease, Cancer etc? If yes specify the
    disease.
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………
    Parent Name ………………………………………….

    Signature ……………………………………………….

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