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1 Hyde School 海德学校 PHYSICAL EXAMINATION Hyde School 616 High Street 616 High 街 IMMUNIZATIONS 150 Route 169 PO Box 237 Bath, ME 巴斯, 缅因州 Woodstock, CT Fax 电话 : Fax Fax Name of Student Date of Birth 学生姓名出生日期 Allergies 过敏史 Height Weight B/P Respirations Pulse 身高体重血压呼吸脉搏 key: Ö - normal + - abnormal ++ - treatment needed 正常不正常需要治疗 Skin 皮肤 Tonsils 扁桃腺 Thyroid 甲状腺 Kidneys 肾脏 Hair 毛发 Teeth 牙齿 Breast 胸部 Hernia 疝气 Nails 指甲 Gums 牙龈 Lungs/Thorax 肺 / 胸腔 Genitalia 生殖器 Eyes 眼 Mouth 口腔 Heart 心 Rectum 直肠 Vision 视力 R 右 20/ L 左 20/ Tongue 舌 Abdomen 腹部 Back/Spine 背部 / 脊椎 Ears 耳 Nose 鼻 Liver 肝 Extremities 四肢 Hearing 听力 Nodes Spleen 脾 Remarks on Abnormalities: 异常处备注 Neurological and Psychiatric (hospitalization, outpatient treatment, therapy): 神经及精神病史 ( 住院史及门症治疗史 ) Any Chronic Illnesses: 任何慢性疾病 Has this child had chickenpox? Date of illness. If not, student will require vaccinenote date(s) below. 这个孩子曾患水痘吗? 生病日期如果没有, 该学生将需接受疫苗 Any restrictions from activities (must include duration of restriction)? 有任何身体运动限制吗 ( 必须注明限制期限 )? Medications (Physician's Request for Medication Administration needs to be completed by the prescribing doctor) 药物 ( 如该生的医师需要学校医药部门开处方药, 需该医师填写药物申请表 ) IMMUNIZATION HISTORY 免疫史 PRIMARY IMMUNIZATION SERIES 主要的疫苗 OTHER 其他疫苗 1ST DOSE 2ND DOSE 3RD DOSE 4TH DOSE 5TH DOSE IMMUNIZATIONS 第一针第二针第三针第四针第五针 VACCINE TYPE MO/DAY/YR MO/DAY/YR MO/DAY/YR MO/DAY/YR MO/DAY/YR DATE VACCINE VACCINE 疫苗种类月 / 日 / 年月 / 日 / 年月 / 日 / 年月 / 日 / 年月 / 日 / 年日期疫苗疫苗 DTP 百白破 TD 白喉破伤风 POLIO 脊髓灰质炎 poliomyelitis??? HIB MEASLES 麻疹 MUMPS 腮腺炎 RUBELLA 风疹 MMR 麻风腮 HBV Meningococcal??? 流脑 meningitis 乙脑 japanese encephalitis Varicella (disease or immunization? 水痘 PPD-REQUIRED FOR FIRST YEAR ENTRANCE AT HYDE SCHOOL 海德第一年学生必须提前接种 PPD. Examiner's Name Typed or Printed: Telephone: 检查者姓名打印或正楷书写电话 Address Fax: 地址传真 Signature Date Signed: Date of exam: 签名签名日期 (PLEASE CONTINUE ON BACK PAGE ) 体检日期 ( 请继续到下一页 ) g:\health center\forms\physical examination updated 8/11/2009

abnormal ++ - treatment needed 正常不正常需要治疗 Skin 皮肤 Tonsils 扁桃腺 Thyroid 甲状腺 Kidneys 肾脏 Hair 毛发 Teeth 牙齿 Breast 胸部 Hernia 疝气 Nails 指甲 Gums 牙龈 Lungs/Thorax 肺 / 胸腔 Genitalia 生殖器 Eyes

2 PHYSICAL EXAMINATION 体检表 PAGE 2 第二页 Student s Name 学生姓名 CARDIOVASCULAR HISTORY 心血管病史 1. Prior occurrence of exertional chest pain/discomfort or syncope/near syncope as well as excessive, unexpected, and unexplained shortness of breath or fatigue associated with exercise? 过去曾有任何胸部疼痛不适, 或发生过昏厥 / 近似昏厥, 或曾有过任何突然的, 原因不明的, 因运动而引起的极度呼吸短促或疲乏吗? Yes No If yes, please explain 是否如选是, 请解释 2. Past detection of a heart murmur or increased blood pressure? 过去曾有心杂音或高血压病史吗? Yes No If yes, please explain 是否如选是, 请解释 3. Family history of premature death (sudden or otherwise), or significant disability from cardiovascular disease in close relative(s) younger than 50 years old, or specific knowledge of the occurrence of certain conditions (e.g. hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan s syndrome, or clinically important arrhythmias)? 家庭病史中曾有过任何早夭 ( 突然的或其他原因 ), 或在 50 岁以下的近亲中曾有因心血管疾病导致严重残疾的, 或曾有任何值得关注的心血管症状的病史吗 ( 比如 : 心肌症, 扩大型心肌症, 或严重心律失常 )? Yes No If yes, please explain 是否如选是, 请解释 CARDIOVASCULAR ASSESSMENT/TESTING 心血管检测 1. Auscultation to identify heart murmurs, especially any murmur suggestive of dynamic left ventricular outflow obstruction: 听诊心杂音, 尤其注意任何可能暗示左心室血液外流障碍的杂音 : Sitting Standing 坐立站立 2. Evaluation of femoral artery pulses to exclude coarctation of the aorta: 检查股动脉来排除大动脉收缩的可能性 : Left Right 左右 3. Identification of any physical signs of Marfan s syndrome? 检查有无任何的症状? Yes No G:health center\forms\cardiovascular history.doc Updated 8/11/09

过去曾有任何胸部疼痛不适, 或发生过昏厥 / 近似昏厥, 或曾有过任何突然的, 原因不明的, 因运动而引起的极度呼吸短促或疲乏吗? Yes No If yes, please explain 是否如选是, 请解释 2.

3 是否 4. If indicated: EKG results 如需要请填写 Echocardiogram results 超声波心动 ( 描记 ) 图结果 Other 其他 G:health center\forms\cardiovascular history.doc Updated 8/11/09

4 INFLUENZA VACCINE CONSENT 流感疫苗同意书 AND 以及 ADMINSTRATION RECORD 注射记录 Flu vaccines will be administered late October / early November (pending supply arrival). There will be a $10 charge applied to the student s account to cover the cost of the vaccine. 流感疫苗将会在十月底 / 十一月初注射 ( 具体日期取决于疫苗供给到达时间 ) $10 将会从学生帐户扣除作为疫苗注射费用 Influenza (flu) is a serious lung disease caused by a virus that spreads from person to person. Influenza can cause fever, headache, sore throat, chills, cough, muscle aches. 流行性感冒是由流感病毒传播的一种严重的肺部疾病流感可以导致发烧, 头痛, 喉咙痛, 发冷, 咳嗽, 以及肌肉疼痛 Who should get the influenza vaccine? Any individual age 65 or older, adults and children with chronic illnesses, anyone whose immune system is compromised, health care workers, and anyone else who wants to decrease the chance of getting the flu. 谁应该接种流感疫苗? 任何年龄超过 65 岁的老年人, 有慢性疾病的成人以及儿童, 任何免疫系统衰弱的人, 健康护理工作人员, 和任何希望降低感染流感机会的人 Who should NOT get the influenza vaccine? Anyone allergic to eggs, chicken feathers or dander, Gentamycin, Thimerosal, anyone sick with a fever, or anyone with a history of Guillain-Barre Syndrome. Anyone who has ever had a serious reaction to any vaccine in the past should also not receive the flue vaccine. If you are pregnant, you should consult with your physician or obstetrician about receiving the vaccine. 谁不应该接种流感疫苗? 任何对鸡蛋, 鸡毛或鸡皮屑, 噻汞撒消毒液原料过敏的人, 任何发烧的病人, 或任何有病史的人在过去曾对任何疫苗有剧烈反应的人也不应该接受流感疫苗如果你怀孕了, 你应该咨询你的医生或产科医师关于流感疫苗注射 The vaccination will protect most people against most strains of influenza. The vaccine is updated yearly. It will begin to provide its protective effect after one to two weeks and will last for several months. Flu vaccines will not protect all persons who get them against influenza, but should at least decrease the severity of the illness. 流感疫苗将会保证大部分人不感染大多数流感菌种该疫苗每年更新换代, 并将在接种后一直两个星期内发挥效力其有效期长达数月流感疫苗并不能保证所有接种者都不得流感, 但至少会降低感染的可能性 I have read, or had explained to me, the above information, and have had a chance to ask questions. I understand the benefits and risks of vaccination and request that the vaccine be given to me or the person named below for whom I am authorized to sign. 我已阅览, 或以获悉, 以上信息, 并已有机会询问我知道疫苗的好处与风险, 并授权给于本人流感疫苗, 或授权给于以下学生流感疫苗 W:\Admiss\International\Chinese FLu shot consent form.doc Updated 8/11/09

流感疫苗将会在十月底 / 十一月初注射 ( 具体日期取决于疫苗供给到达时间 ) $10 将会从学生帐户扣除作为疫苗注射费用 Influenza (flu) is a serious lung disease caused by a virus that spreads from person to

5 Student Name: Date: (Please Print) 学生姓名 ( 请写正楷 ) 日期 Signature of Parent/Guardian: Relationship: 家长 / 监护人签字关系 FOR CLINIC/OFFICE USE 校医使用栏 Hyde School 616 High Street, Bath, ME Name of Clinic Address Manufacturer and Lot Number Site of Injection Chronic Disease Signature of Vaccine Administrator Date W:\Admiss\International\Chinese FLu shot consent form.doc Updated 8/11/09

$Injection Chronic Disease Signature of Vaccine Administrator Date W:\Admiss\International\Chinese FLu shot consent form.$

6 MEDICAL EMERGENCY CONSENT GENERAL INFORMATION 紧急医疗同意书信息概要 Student's Name Last First Middle Date of Birth Social Security Number 学生姓名姓名出生日期 Home Address of Student Number and Street City State Zip 学生家庭住址门牌街区号城市省邮政编码 Student resides with: Both Parents Father Mother Other 学生共住于父母只与父亲共住只与母亲共住其他 Father's full name Res. Phone ( ) 父亲全名家庭电话 Street Address Bus. Phone ( ) 家庭住址 ( 门牌街区号 ) 工作电话 City, State & Zip Cell Phone ( ) 城市, 省以及邮编手机 Mother's full name Res. Phone ( ) 母亲全名家庭电话 Street Address Bus. Phone ( ) 家庭住址 ( 门牌街区号 ) 工作电话 City, State & Zip Cell Phone ( ) 城市, 省以及邮编手机 Name of Medical Insurance Company Phone ( ) 医疗保险公司名称 Address for insurance company 医疗保险公司地址 Pre-authorization required? Yes No Drug Plan? Yes No (Provide Copies of front and back of insurance cards) 是否药物计划? 是否 ( 请提供保险卡正反面的复印件 ) Certificate/Policy numbers (include group number if applicable) Name of policy holder SSN Date of Birth Address of policy holder 生日 Policy holder's employer Alternate responsible person (not parent) to be reached in case of emergency if parent or guardian is unavailable: 另外的紧急联系责任人 ( 非父母 ) 如果父母或监护人无法联系 : Name 姓名 Phone: 电话

Phone ( ) 父亲全名家庭电话 Street Address Bus. Phone ( ) 家庭住址 ( 门牌街区号 ) 工作电话 City, State & Zip Cell Phone ( ) 城市, 省以及邮编手机 Mother's full name Res.

7 Address 地址 Student s known allergies: 学生过敏史 Medication student currently taking: 学生当前正在用的药物 Pertinent Medical History: 相关的医疗历史 Physical Limitations: 身体活动限制 Last Tetanus Immunization: 最近的一次破伤风疫苗 I hereby give consent for the Director of Health Services, School Nurse, Hyde School Faculty, or other health care providers considered appropriate by him/her to carry out accepted procedures for diagnosis, immunization, medical, dental, and minor surgical treatment, or counseling for my (son, daughter, ward). I also authorize the Health Services Department of Hyde School to share medical information (physical and/or mental health) with employees of Hyde School including, but not limited to, faculty, coaches, dorm parents and administration, for the purpose of coordinating and facilitating the overall well being of my (son, daughter, ward). This authorization will be in effect for a period of one year. I may revoke this authorization at any time by executing a written revocation addressed to the Hyde School Health Center. I am entitled to a copy of this authorization form and will request one if I desire to have one. 我特此同意健康服务主任, 校医, 海德学校教职工, 或其他卫生保健部门提供他们认为适合我孩子的诊断免疫程序, 以及提供牙科小型手术治疗, 和医疗咨询我批准海德学校健康服务部门与海德学校教职工体育教练宿舍管理员和行政部门分享这些医疗信息 ( 身体和 / 或精神的健康状况 ), 以此来保证我的孩子的健康这份授权书有效期一年我有权随时将书面申请寄给海德学校健康中心来撤回此授权书我有权随我的意愿要求得到这份授权书的副本 Name: 姓名 Signature: 签名 Date: 日期 Relationship: 关系 In rare instances a surgical emergency arises in which written consent by the parent or guardian is legally required. In this event and in order to avoid delay which might jeopardize the life or recovery of a student, we request the following permission from the parents or guardian, with the understanding that every effort will be made to contact the parents or guardian in case of any emergency. I hereby grant permission to the Director of Health Services, School Nurse or Hyde School Faculty to give consent for necessary anesthesia and emergency surgical procedures on my (son, daughter, ward). 在罕见情况下一些紧急外科治疗须经过父母或监护人书面同意方能合法实施因此我们要求父母或监护人提前签订授权书以免在紧急状况下对学生的生命或恢复造成任何伤害或阻滞我特此批准健康服务中心主任校医或海德学校教职工同意我的孩子接受麻醉和紧急手术措施 Name: 姓名 Signature: 签名 Date: 日期 Relationship: 关系

carry out accepted procedures for diagnosis, immunization, medical, dental, and minor surgical treatment, or counseling for my (son, daughter, ward).

8 药物治疗授权表所有学生务必填写学生姓名 : 日期 : 家长 / 监护人 : 1) 我已阅览了附带的海德学校医疗政策并同意学校的护士以及被指派者按照家庭医生或校医的指示来给我的儿子 / 女儿开处方药和非处方药家长姓名首写字母 : 2) 我允许我的儿子 / 女儿自带一天剂量的药物 ( 这是为了体育外出比赛或其他需要离校的活动 ) 家长姓名首写字母 : 3) 我允许我的儿子 / 女儿携带并使用下列紧急药品 : 吸入式哮喘药物, 或肾上腺素自动注射器家长姓名首写字母 : 4) 我知道学生放假回家时不允许携带任何药物家长姓名首写字母 : 5) 您允许您的孩子在学年以及暑假活动结束时携带药物回家吗? 允许不允许 ( 如果家长不同意孩子自带药物回家, 家长必须以手写形式通知学校健康中心药物的邮寄地址 ) 6) 我已阅览了学生有关药物的责任, 并同意遵守其内容家长姓名首写字母 : 家长签名 : 学生签名 :

: 吸入式哮喘药物, 或肾上腺素自动注射器家长姓名首写字母 : 4) 我知道学生放假回家时不允许携带任何药物家长姓名首写字母 : 5) 您允许您的孩子在学年以及暑假活动结束时携带药物回家吗?

9 PERSONAL MEDICAL HISTORY NEW STUDENTS ONLY 新生个人医疗历史 Student's Name 学生姓名 Date 日期 This information is for the use of Health Services in providing necessary health care while you are a student at Hyde School. This side is to be filled out by student and/or parent/guardian. All questions must be answered. Comment on all "yes" answers below. 健康服务中心将使用该信息为您在海德学习期间提供需要的健康护理这一面需要学生和 / 或家长 / 监护人填写所有问题均需回答请解释以下所有的是选项 AGE STATE OF OCCUPATION YEAR OF 年龄 HEALTH 职业 DEATH 健康状况过世多久 Father 父亲 Mother 母亲 Brothers 兄弟 Sisters 姐妹 ALLERGIES 药物过敏 YES 是 NO 否 Penicillin 青霉素 Sulfa Drugs 磺胺药 Other meds (list) 其他药物 ( 请列举 ) Food (list) 食物 ( 请列举 ) Bee Stings (Send ANKIT) 蜂蜇 ( 寄解毒剂 ) Insect Bites 昆虫蜇咬 Poison Oak or Ivy 毒葛 Hay Fever 花粉热 Describe any reactions: 请描述反应症状 Date of last dental exam 最近的牙医检查日期 SURGERIES 手术 YES 是 DATE 日期 NO 否 Appendectomy 阑尾切除术 Tonsillectomy 扁桃腺切除术 Hernia Repair 疝气修复手术 Other 其他 COMMENTS: 注释 G:\health center\forms\personal medical history updated 8/11/2009

健康服务中心将使用该信息为您在海德学习期间提供需要的健康护理这一面需要学生和 / 或家长 / 监护人填写所有问题均需回答请解释以下所有的是选项 AGE STATE OF OCCUPATION YEAR OF 年龄 HEALTH 职业 DEATH 健康状况过世

10 check if yes 如曾有下列疾病请打勾 STUDENT/FAMILY HISTORY 学生 / 家庭历史 Student 学生 Family Member 家庭成员 Anemia or Blood Disorder 贫血症或其他血液疾病 Arthritis 关节炎 Asthma, Hay Fever 哮喘, 花粉热 Chicken Pox 水痘 Chronic Cough 慢性咳嗽 Dental or Gum Problems 牙齿或牙龈问题 Diabetes 糖尿病 Eatings Disorder (anorexia/bulemia) 厌食暴食症 Eczema/Skin Problem 湿疹 / 皮肤问题 Epilepsy, Convulsions 癫痫, 痉挛 Eye Problem 眼睛问题 Frequent Anxiety 频繁的忧虑症 Frequent Bronchitis 频繁的支气管炎 Frequent Depression 频繁的抑郁症 Frequent Ear Infections 频繁的耳朵感染 Frequent Strep Throat 频繁的喉部链锁状球菌感染 Frequent Tonsillitis 频繁的扁桃腺炎 Frequent Urinary Tract Infection 频繁的尿道感染 Gall Bladder Disorder 胆囊紊乱 Head injury w/ loss of consciousness 头部受伤并失去意识 Heart Disease 心脏疾病 High or Low Blood Pressure 高或低血压 Insomnia 失眠 Jaundice/Hepatitis 黄疸 / 肝炎 Kidney Disease 肾脏疾病 Migraines 偏头痛 Mononucleosis 单核细胞增多症 Pain/Pressure in Chest 胸部疼痛 Palpitations or Heart Murmur 心杂音 Recurrent Headache 周期性头痛 Rheumatic Fever 风湿热 Shortness of Breath 呼吸短促 Sinusitis 窦炎 Stomach/Intestinal Problems 胃肠问题 Thyroid Disorder 甲状腺紊乱 Tobacco Use 使用烟草 Tuberculosis 肺结核 Tumor/Cancer 肿瘤 / 癌症 Ulcer 溃疡 Female Students Only 女性学生需填写 History of Pregnancy 怀孕历史 Severe Cramps 严重经痛

挛 Eye Problem 眼睛问题 Frequent Anxiety 频繁的忧虑症 Frequent Bronchitis 频繁的支气管炎 Frequent Depression 频繁的抑郁症 Frequent Ear Infections 频繁的耳朵感染 Frequent Strep Throat 频繁的喉部链锁状球菌感

11 Irregular Periods 经期不调 Excessive Flow 月经量过大 Use of Birth Control 节育措施 Breast Disorder 乳房疾病 Other (Describe) 其他 ( 请描述 )

12 SKELETAL SYSTEM-Please check the appropriate box and indicate year and right or left if you have ever had any of these problems 骨骼系统 - 如果有下列骨骼状况请在表格中打勾, 并标明左右. KNEE 膝盖 ANKLE, LOWER LEG ARM, WRIST HIPS, BACK **please indicate year also FOOT, TOES 小腿, 胫 FINGERS, HANDS GROIN, THIGH 背部脚踝脚脚趾手臂手腕臀腹股沟手指手大腿请注明年份 right left right left right left right left right left 右左右左右左右左右左 Fracture 骨折 Sprain/Strain 扭伤 Tendonitis 肌腱拉伤 Dislocation 脱臼 Bursitis 粘液囊炎 Surgery 手术 Swelling 肿胀 Locking Giving Cartilage Problem 软骨问题 Dislocated Kneecap 膝盖骨脱臼 Other 其他 Please use this area to describe any situations marked above. Also, provide the health center with a copy of any pertinent medical findings ( i.e. physical limits placed on student's ability to do sports). 请利用这块区域来描述上面打勾的受伤情况, 并请提供一份病人的重大医疗结论给健康中心 ( 如 : 学生的运动体能限制等 ) Have you had any illness or injury or been hospitalized other than already noted? 你有任何除上述问题以外的疾病受伤或住院史吗? Have you received psychiatric treatment or counseling for a personality or character disorder, drug/alcohol abuse, eating disorder or an emotional problem? 你有接受过精神病治疗性格紊乱疾病咨询吗? 曾滥用毒品 / 酒精或有饮食疾病或情绪问题吗? Has your child had any psychological testing (LD,ADHD, Neuropsych, projective)? If yes, provide a copy of testing to health center. 你的孩子曾接受过任何心理测试吗 ( 神经精神方面,)? Recent change in health status of family member(s)? 最近家庭成员中有健康状况的变化吗? 是否 Yes No If you have answered yes to any of the above questions please use the remaining space for comments and additional information. 如果你对上述任何问题回答了是, 请在以下空白处作解释并提供额外信息 Date 日期 Date 日期 Student Signature 学生签名 Parent/Guardian Signature 家长 / 监护人签名 G:health center\forms\skeletal updated 8/11/2009

left right left right left 右左右左右左右左右左 Fracture 骨折 Sprain/Strain 扭伤 Tendonitis 肌腱拉伤 Dislocation 脱臼 Bursitis 粘液囊炎 Surgery 手术 Swelling 肿胀 Locking Giving Cartilage Problem 软骨问题

13 Mandatory Health Documentation Guidelines (Hyde School) 海德学校健康文件导则 Dear Parent / Guardian, 亲爱的家长或监护人, Please note that all health office paperwork MUST be completed and mailed or faxed to the health office at least 2 weeks prior to registration at Hyde School. All forms MUST be completed in English. 请记得所有健康中心的文件都必须要在注册前至少两星期邮寄或传真至健康中心所有的文件都需要以英文完成 Emergency Medical Consent Please write names and addresses in English and be sure to sign both areas at the bottom of the form. 紧急医疗同意书 : 请用英文写下姓名及地址并确认在同意书最下方签名 Physical A medical physical must be performed with the form completed by a doctor /provider in your home country. We must have a new physical completed each school year. (Dated June 2014 or later) 健康检查 : 健康检查表格须由医生在国内填写完毕我们每年都需要有新的健康检查资料 ( 日期须在 2014 年 6 月之后 ) *Be sure that your child s name, date of birth and any allergies are clearly written at the top of the physical form. * 请确定您的孩子姓名生日及任何过敏历史都非常清楚完整的填写在表格上 Immunizations All immunizations must be completed and up to date as follows: 预防疫苗 : 所有疫苗都需要在以下日期之前接种 DTP (Diphtheria, Tetanus, Pertussis) at least 3 doses (the last one given on or after the 4 th birthday). DTP( 白喉破伤风百日咳疫苗 ) 至少三剂 ( 最后一剂须在 4 岁生日之后接种 ) Tdap (Tetanus / Pertussis) 1 booster vaccine within the last 5 years. Tdap( 破伤风非细菌性百日咳疫苗 )1 剂 - 过去 5 年内接种 Polio At least 3 doses (the last one given on or after the 4 th birthday). 小儿麻痹 - 至少三剂 ( 最后一剂须在 4 岁生日之后接种 ) MMR (Mumps, Measles, Rubella) 2 Doses - 1 dose on or after the 1 st birthday.

请记得所有健康中心的文件都必须要在注册前至少两星期邮寄或传真至健康中心所有的文件都需要以英文完成 Emergency Medical Consent Please write names and addresses in English and be sure to sign both areas at

14 MMR( 麻疹腮腺炎德国麻疹 ) 两剂 - 一剂在一岁生日以后 Hepatitis B 3 doses (completed within a 6 month period). B 性肝炎 -3 剂 ( 在 6 个月之内完成 ) Varicella (chicken pox) Verification of disease (confirmed in writing by Dr.) or 水痘 - 患病证明 ( 医生签署 ) 或 o If over 13 years old, 2 doses given at least 4 weeks apart. o 若 13 岁以上 2 剂疫苗, 其间隔 4 周以上 Meningococcal Vaccine At least 1 for all boarding students (2 if age 16 or over). 脑膜炎球菌疫苗 - 所有寄宿学生都至少一剂 ( 若 16 岁以上则两剂 ) PPD / Mantoux (dated within the last 3 months for all first year students). If it is positive (Equal to or greater than 10 mm) a chest x-ray must be done. Prophylactic treatment is to be considered. 结核菌素试验 ( 所有新生都须在至少过去三个月内接种 ) 若为阳性 ( 等于或大于 10mm) 则需作胸腔 X 光也许考录预防用药的治疗 Personal Medical History Must be completed and signed each year. 个人医疗历史 - 每年都需检查及签名 Medication Authorization Form Must be completed and signed each year. 用药认可表格 - 每年都需检查及签名 FLU Immunization Consent If you wish for your child to receive the flu vaccine in October, please complete and sign the form. (Not mandatory but highly recommended). 刘性感冒疫苗同意书 - 若您希望您的孩子在 10 月接种刘性感冒疫苗, 请完成并签署同意书 ( 非强制但强烈建议 ) *Please put your child s full name on all health documents* * 请在所有健康表格上填上孩子的全名 * Hyde School Health Office, 150 Rt. 169, P.O. Box 237, Woodstock, CT Fax: ws-health@hyde.edu 海德学校健康中心,150 Rt. 169, P.O. 237, Woodstock, CT 传真 / 电邮 : ws-health@hyde.edu

) or 水痘 - 患病证明 ( 医生签署 ) 或 o If over 13 years old, 2 doses given at least 4 weeks apart.

15 TUBERCULOSIS SCREENING Mandatory for all 1 st year Hyde School Students All Screenings must be performed within 3 months of admission to Hyde School Complete documentation must be received PRIOR to travel to Hyde School Student Name: Date of Birth: Date of PPD (Mantoux) Plant: Date of Reading: Result (Read in millimeters): Initial of Provider: Initial of Provider: Initial of Provider: A Chest X-ray must be performed on all students with positive PPD Screenings. Results must accompany this form. If PPD is read as 10 mm or greater, prophylactic treatment for Latent Tuberculosis must be considered. If parent or student over the age of 18 decline prophylactic treatment, we must receive a signed and dated document stating that they were informed of the risks of tuberculosis, the benefits of treatment, and their decision to decline from said treatment. If other testing such as QuantiFERON Gold has been performed, please attach results to this form. Signature of Physician / Provider: Address of Physician: Phone Number / address:

X-ray must be performed on all students with positive PPD Screenings. Results must accompany this form.

网球 / 排球 1 教师硕士四级男性诊断教研室 1 教师博士或硕士六级本科阶段为临床医学专业, 男士温病教研室 2 教师博士或硕士六级中医专业中医诊断教研室诊断学 / 中医诊

网球 / 排球 1 教师硕士四级男性诊断教研室 1 教师博士或硕士六级本科阶段为临床医学专业, 男士温病教研室 2 教师博士或硕士六级中医专业中医诊断教研室诊断学 / 中医诊校本部工程项目管理或土木工程医学类 / 计算机 / 图书馆专业 1 专技硕士以上六级 1 专技硕士以上六级 1 年以上工程造价管理或现场施工管理经验的 ( 限男性 ) 中医药类专业 1 编辑博士六级医学或生物学专业医学或生物学专业 2 实