2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物维生素矿物质或其他营养品? No 否 Yes 是 -----Please lis

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1 Student Medical Form 学生体检表 This form is to be completed for new students upon admission, and returning students prior to starting grades 3 and 6. Secondary students must complete the medical exam every two years in order to participate in after school activities or athletics. The first portion of the form is to be completed by parents, and the second portion of the form is to be completed by a physician. 所有新生都需要完成健康体检表对于在校生, 即将进入三年级六年级的学生也需要完成体检表对于中学部学生, 如果需要参加学校体育课或者体育比赛, 请每两年提交一次体检表在体检表中, 第一部分需要父母填写, 第二部分需要医生填写 To be completed by parents: 此部分由父母填写 : Emergency Medical Evacuation Insurance 紧急医疗情况 : Does your child have International SOS or other emergency medical evacuation coverage? 您是否已经为孩子购买国际性保险或其他紧急医疗保险? No 没有 Yes---- Please complete 有 --- 请提供详细内容 : Name of company 保险公司名称 : Contact # 联系电话 : Policy # 保险单号 : Medications 药物治疗 : Attention: If you want your child to take medication at school, you must send a note with the medication with the name of the medication, dose (how much), time to take the medication, and for how many days. 请注意 : 如果您希望您的孩子在学校服用药物, 必须提供药物名称用药量服药时间及持续用药时间的详细情况 1. The nurse s office has the following medications. Please check the box next to the medication which gives the school nurse permission to give it to your child if needed. 我们学校医务室有以下药物如果发生特殊情况, 您的孩子需要采取药物治疗, 如果您允许校医使用以下药物, 请您在允许使用的药物名称前面打勾 Throat Lozenges- for sore throat relief 润喉片 - 用于缓解咽喉疼痛 Acetaminophen/Paracetamol (Tylenol)- for headaches, fever and cramps 对乙酰氨基酚 / 对乙酰氨基 ( 泰诺 )- 用于头痛发烧痉挛 Ibuprophen (Motrin)- for headaches, fever and cramps 芬必得 ( 美林 )- 用于头痛发烧痉挛 Diphenhydramine (Benadryl)- for allergic reactions 苯海拉明 ( 可他敏 )- 用于过敏反应 Topical ointments and lotions- for grazes, cuts and rashes 外用药膏和洗剂 - 用于擦伤割伤疹子 Tums (Antacid/ Calcium supplement)- for stomach aches 碳酸钙片剂 ( 制酸药 / 钙试剂盒 )- 用于胃疼 Page 1 of 6

2 2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物维生素矿物质或其他营养品? No 否 Yes 是 -----Please list name of medication, dose, and reason for medication 请列出服用的药物或营养品的名称用量和使用原因 : o o o Allergies 过敏反应 : 1. Is your child allergic to any medication, food, or environmental factor? 您的孩子是否有药物 / 食物 / 环境过敏的问题? No 否 Yes 有 Please list allergies and reactions 如果有, 请详细列举 : o o o Health Conditions 健康状况 : Does your child have a history of any of the following conditions? 您的孩子在过去是否曾经出现以下问题? Concussion 脑震荡 Asthma 哮喘病 Breathing Problems 呼吸问题 Seasonal Respiratory Allergies 季节性呼吸道过敏 Diabetes 糖尿病 Seizures (Epilepsy) 癫痫 Heart Problems 心脏问题 Serious injuries 严重外伤 Eye Problems 眼睛问题 Bone or Joint Problems 骨或关节问题 Serious Accidents 重大事故 Chronic cough 慢性咳嗽 Glasses or Contacts (circle which one/s) 带眼镜或隐形眼镜 Skin Problems 皮肤问题 Cancer 癌症 ADHD /ADD 注意力缺失过动症 / 注意力缺陷障碍 Frequent Headaches 经常性头疼 Severe Menstrual Cramps 严重的月经来潮 Chicken Pox 水痘 Hearing Problems 听力问题 Teeth or Mouth Issues 牙齿或口腔问题 Anxiety/ Depression/ Bipolar (circle which one/s) 焦躁 / 抑郁 / 双相情感障碍 Chronic Diseases 慢性病 Fever of more than 2 weeks 连续 2 周以上发烧 Unexplained weight loss 不明原因的体重减轻 Frequent Stomach aches 经常胃疼痛 Anemia 贫血 Page 2 of 6

3 Bladder or Kidney Blood or clotting Other Problems 膀胱或肾脏 disorders 血液或凝血其他问题障碍 None of the Above Hepatitis 肝炎 Frequent Nose Bleeds 频繁流鼻血以上全无 Please explain any checked boxes and give any additional information that would help the teachers or school nurse in the care of your child during the school day: 如果您在以上的某项或某几项打勾了, 请详细说明情况, 以便学校老师和校医可以在上学期间更好地帮助您的孩子 : PARENT SIGNATURE 父母签名 : Date 日期 : Page 3 of 6

4 To be completed by a medical physician 医生填写 : Height (cm) 身高 ( 厘米 ): B/P 血压 : / Weight (kg) 体重 ( 公斤 ): Pulse 脉搏 : Surgical History: Has the child undergone any surgical procedure? 孩子是否接受过任何手术? No 无 Yes 有 Please specify when and the nature of surgery 请详细说明手术情况 : Physical Activities 体育活动 (Normal physical education classes, swimming and competitive sports)( 一般的体育课程, 游泳和体育比赛 ) Unrestricted 没有限制 Modified 不能参加的体育活动 --- Please explain 请解释 : Physical Exam 体检 : General Appearance 一般情况 Neurologic 神经系统 Normal 正常 Abnormal 不正常 Physician s Comments, Findings,Tests,ETC. 医生的意见, 结论, 测试等 Musculoskeletal 肌肉骨骼系统 Skin, Scalp 皮肤, 头皮 Eyes 眼睛 Vision Screening 视力 Ear, Nose, Throat 耳, 鼻, 喉 Hearing Screening 听力 Speech 语言 Mouth, Teeth 口, 牙齿 Glands, Thyroid 腺体, 甲状腺 Heart 心脏 Lungs 肺部 Abdomen 腹部 Genitourinary 泌尿生殖器 Mental Health and Cognition 精神健康和认知 Emotional Health +Behavioral Health 情感健康 + 行为健康 Page 4 of 6

5 Vaccinations 疫苗接种记录 : The below vaccinations are REQUIRED for WYIS school attendance. Please write the DATES the child has received the below vaccinations. Please attach a copy of the child s vaccination record. Note: Some vaccinations are given in combination <Example: Measles, Mumps, Rubella (MMR)>. 以下是所有录入武汉长江国际学校的学生在入学前必须完成的疫苗接种内容请详细填写具体的接种完成日期另外, 请您附上学生的疫苗接种记录复印件注意 : 有一些疫苗是联合疫苗 ( 例如 : 麻风腮联合疫苗中包括了麻疹疫苗, 风疹疫苗和腮腺炎疫苗 ) Required Vaccinations 必须注射的疫苗 Date (mm/dd/yy) 具体日期 ( 月 / 日 / 年 ) Type 类型名称 1 st 第一针 2 nd 第二针 3 rd 第三针 4 th 第四针 5 th 第五针 Polio: 3-4 doses with at least one dose of Inactivated Polio Vaccine (IPV) required before start of school 脊髓灰质炎疫苗 ( 小儿麻痹疫苗 ): 一共是 3-4 针, 上学前至少需要完成一针灭活脊髓灰质炎疫苗 Diphtheria, Tetanus, Pertussis (DTP): 3 primary doses required before start of school; booster dose required age 1-6; booster of Td age 百白破疫苗 : 三项基础针在上学前需要完成,1-6 岁需要完成加强针,12-15 岁需要完成白喉疫苗 Measles: 1 dose required before start of school; 2nd dose required by age 6 麻疹疫苗 : 第一针需要在上学前完成, 第二针需要在 6 岁前完成 Mumps: 1 dose required before start of school; 2nd dose required by age 6 腮腺炎疫苗 : 第一针需要在上学前完成, 第二针需要在 6 岁前完成 Rubella: 1 dose required before start of school 风疹疫苗 : 需要在上学前完成 Hepatitis B: 3 doses required by start of school 乙肝疫苗 : 在上学前必须完成全部的 3 针 This student has completed the minimal immunization requirements for attendance at WYIS : 该学生已经完成在 WYIS 上学所必须的免疫接种 : Yes 是 No 否 Communicable Disease 传染疾病 In my opinion this student is free of any communicable disease. 据我看来, 此学生无任何传染病 Yes 是 No 否 Page 5 of 6

6 Tuberculosis Assessment( 肺 ) 结核病测试结果 : All students attending WYIS must have a negative PPD or chest x-ray within the last 6 months, unless they have had a BCG vaccination within the last 5 years. 所有申请进入武汉长江学校的学生, 需要提交在过去半年中进行结核菌素测试并呈阴性的结果或者胸透检查的结果, 除非他们在过去 5 年中进行过卡介苗疫苗接种 1. BCG vaccination received? 是否曾经接种卡介苗疫苗? No 否 Yes 是 --- Date receive 具体的接种日期 : 2. Last PPD date and result 最近一次参加结核菌素测试的日期及结果 : 3. Last chest x-ray date and result 最近一次参加胸透检查的日期及结果 : This patient has had a negative PPD or chest x-ray within the past 6 months. 学生已在过去半年内进行结核菌素测试并呈阴性, 或者已经在过去半年内进行胸透检查 Yes 是 No 否 ---- Please indicate reason 请说明原因 : o PPD/ Chest x-ray assessment was deferred due to BCG within past 5 years. 因为在过去 5 年内进行过卡介苗疫苗接种, 所以推迟进行结核菌素测试或胸透检查 o Other 其他原因 ( 请说明 ): In my assessment, this patient is free of any signs or symptoms of tuberculosis: 在我的检查中, 该学生没有出现任何 ( 肺 ) 结核病的迹象或症状 : Yes 是 No 否 --- Please explain 请说明情况 : Additional Comments 其他附加信息 : Doctor s Name 医生姓名 (Block Letters 大写 ): Signature 签名 : Date of Examination 体检日期 : Office Stamp: 医生办公印章 Page 6 of 6

2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物维生素矿物质或其他营养品? No 否

2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物维生素矿物质或其他营养品? No 否 Student Medical Form 学生体检表 This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete

2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物 维生素 矿物质或其他营养品? No 否 Yes 是 -----Please lis

2. Does your child take any medications, vitamins, minerals, or supplements on a regular basis? 您的孩子是否定期服用药物维生素矿物质或其他营养品? No 否 Yes 是 -----Please lis