| HOME | E-MAIL | THE METHOD | THE SCHOOL | FEES | REQUEST INFORMATION | DOWNLOADS |

head1.gif (17527 bytes)

The Method

The School

Fees

Request Information

 

Please fill in the Child's Medical History Form below.
Should you prefer to fax this form, please choose the PDF version.

Online Version
PDF Version

CHILD'S MEDICAL HISTORY FORM

REQUIRED FIELDS ARE BOLD!

Surname:
First Names:
Date Of Birth:
Place Of Birth:

RECORD OF VACCINATIONS/DISEASES

Please record whether or not your child has had the following illnesses, along with the dates of any vaccinations where appropriate.
ILLNESS DATE(S) of vaccinations   DATE(S) of illness, if applicable
DIPHTHERIA  
WHOOPING COUGH  
TETANUS  
POLIO  
MEASLES  
MUMPS  
RUBELLA (German measles)  
BCG (for Tuberculosis)  

UNUSUAL ILLNESSES

Excluding common illnesses, please list any unusual problems:

ALLERGIES 

Does your child have any allergies?
Please include any allergies to medication:

EAR, NOSE & THROAT PROBLEMS

Please list any unusual problems your child has had in hearing,
ear infections, breathing (Asthma)throat etc:

OTHER RELEVANT MEDICAL INFORMATION

Is the child using any medication?
Has he/she ever been in hospital?:

DETAILS OF FAMILY DOCTOR

Please give full name and address of family doctor,
including telephone number:

EMERGENCY CONTACTS

Who should we contact in case of emergency?
Please give two names and telephone numbers.

Name:
Telephone:
Relationship to the child:

Name:
Telephone:
Relationship to child:

I / We hereby certify that the information given above is true and correct in all particulars.
I / We authorise Montessori House Belgium to provide medical treatment in case of emergency.

ADRESS

Street & No.:
City & Postcode:
Country:
E-Mail Address:

or

 

| DOWNLOADS | REQUEST INFORMATION | THE METHOD | THE SCHOOL | FEES | E-MAIL | HOME |

maroonline.gif (889 bytes)

 

Copyright @ Montessori House Belgium 2000-2008, all rights reserved.
Last update : 20/08/2008
Site Created by Genitronics