Stleonards.vic.edu.au

MEDICAL PROFILE AND INFORMATION
To be completed for all new students.
Please print, complete, sign and return to Registrar’s Office.

Student’s name: __________________________________Year level in 2012:___________

Section 1 (to be completed by parents)
Please tick which immunisations your child (Please tick if appropriate and provide full details) Does your child suffer from any of the following? (Give details of any special care recommended by parent or student ’s doctor) Does your child have any other physical limitations or medical conditions? Is your child allergic to any drugs or foodstuffs? administration of medication during school (If yes, please ensure medication is clearly labeled with stude dosage and instructions as per treating medical doctor) MEDICAL PROFILE AND INFORMATION
To be completed for all new students.
Please print, complete, sign and return to Registrar’s Office.

All students commencing at St Leonard's College are requested to undertake a general physical
examination in order to ensure that any health issues that may affect their education are identified
so that the College can assist them with their individual needs. Please ask your family doctor to
complete the following information (where age appropriate).
Student’s name: __________________________________ Year level in 2012:___________

Section 2 (to be completed by the family doctor)
Asthma management (if applicable)
Has the child suffered sudden severe asthma attacks? Has the child been admitted to hospital due to asthma in the past year? Has the child been on oral cortisone for asthma within the past year? Please provide asthma management plan as prescribed I give permission for a staff member to administer ventolin if my child Any additional comments – please give details of allergies

Doctor's name: ______________________________________________________________

Signature: _________________________________ Date: ____________________________

Parent's / guardian's signature: ________________________________ Date: ___________
AUTHORISATION FOR NURSING STAFF TO ADMINISTER
NON-PRESCRIPTION OR OVER THE COUNTER MEDICATION/CREAMS

To be completed for all new students.
Please print, complete, sign and return to Registrar’s Office.

Student’s name: __________________________________ Year level in 2012:____________

The following non-prescription or 'over the counter' medications are held in the Health Centre for
the relief of minor illnesses. Please tick EACH medication you authorise the Registered Nursing
Staff to administer to your son/daughter if required.
MEDICATION
authorised
Cough mixtures (expectorants & suppressants)
Parent's / guardian's signature: _________________________________________________

Source: http://www.stleonards.vic.edu.au/Documents/2012/Brighton%20MEDICAL%20PROFILE%20AND%20INFORMATION%20form%202012.pdf