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Medical details form

Medical Details Form
Student’s Name: ______________________________________ Year Level: _______
Roll Class: _______
My child does not have any known medical conditions My child has the following known medical conditions. Medical Condition 1:
Medical Condition Category:

(Please use list of Medical Condition
Categories provided)
Symptoms:
(Include specific medical condition
name if known and any symptoms
school should look for)
Management: (Include any special
instructions the school should follow
with regard to this condition)

Medical Condition 2:
Medical Condition Category:

(Please use list of Medical Condition
Categories provided)
Symptoms:
(Include specific medical condition
name if known and any symptoms
school should look for)
Management: (Include any special
instructions the school should follow
with regard to this condition)

Medical Condition 3:
Medical Condition Category:

(Please use list of Medical Condition
Categories provided)
Symptoms:
(Include specific medical condition
name if known and any symptoms
school should look for)
Management: (Include any special
instructions the school should follow with regard to this condition) If your child has additional medical conditions please attach details of all medical conditions. __________________________ Education Queensland Standardised Medical Condition Category List
Acquired brain injury
Allergies/Sensitivities
Anaphylaxis
Airway/lung/breathing – Oxygen required (continuously/periodically)
Airway/lung/breathing – Suctioning
Airway/lung/breathing - Trachestomy
Airway/lung/breathing – Other
Artificial feeding – Gastrostomy device (tube or button)
Artificial feeding – Nasogastric tube
Artificial feeding – Jejunostomy tube
Artificial feeding – Other
Asthma
Attention-deficit/Hyperactivity disorder (ADHD)
Bladder and bowel – Urinary wetting, incontinence
Bladder and bowel – Faecal soiling, constipation, incontinence
Bladder and bowel – Catheterisation (continuous, clean intermittent)
Bladder and bowel – Stoma site, urostomy, Mitrofanoff, MACE, Chair
Bladder and bowel – Other
Blood disorders – Haemophilia
Blood disorders – Thalassaemia
Blood disorders – Other
Cancer/oncology
Coeliac disease
Cystic Fibrosis
Diabetes – type one
Diabetes – type two
Ear/hearing disorders – Otitis Media (middle ear infections)
Ear/hearing disorders – Hearing loss
Ear/hearing disorders – Other
Epilepsy – Seizure
Eye/Vision disorders
Endocrine disorder – Adrenal hypoplasia, pituitary, thyroid
Heart/cardiac conditions – Heart valve disorders
Heart/cardiac conditions – Heart genetic malformations
Heart/cardiac conditions – Other
Mental Health – Depression
Mental Health – Anxiety
Mental Health – Oppositional defiant disorder
Mental Health – Other
Muscle/bone/musculoskeletal disorders – spasticity (Baclofen Pump)
Muscle/bone/musculoskeletal disorders – Other
Skin disorders – eczema
Skin disorders – psoriasis
Swallowing/dysphagia – requiring modified foods
Swallowing/dysphagia – requiring artificial feeding
Transfer & positioning difficulties
Travel/motion sickness
Other

Source: http://www.ipswwestss.eq.edu.au/forms/Medical%20Details%20Form.pdf

Susie h

CURRICULM VITAE Susie H. Park, Pharm.D., BCPP, FCSHP PERSONAL INFORMATION Title: Assistant Professor of Clinical Pharmacy and Pharmaceutical Economics and Policy University of Southern California School of Pharmacy 1985 Zonal Avenue Los Angeles, CA 90033-0804 EDUCATION 1989-1993 University of California, San Diego La Jolla, California Bachelor of Arts Psychology (Cum La

Microsoft word - scabies treatment-prophylaxis.doc

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