SCHOOL MEDICAL FORM

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– Step 1 of 3

NAME OF STUDENT *

EMERGENCY TEL. NUMMBER *

EMAIL ADDRESS *

DATE OF BIRTH *

NATIONALITY *

NAME OF THE PERSON *

HIS/HER PHONE NUMBER *

YOUR RELATIONSHIP WITH THE PERSON *

a. CONTAGIOUS DISEASES *

b. ALLERGIC DISEASES *

c. METABOLIC DISEASES *

d. CARDIOVASCULAR DISEASES *

e. DISEASES OF THE NERVOUS SYSTEM *

f. DISEASES OF THE DIGESTIVE SYSTEM *

g. DISEASES OF THE RESPIRATORY TRACT *

h. HEAMATOLOGICAL DISEASES *

i. DISEASES OF THE MUSCLES/BONES *

j. OTHER DISEASE *

k. SURGERY *

l. ACCIDENTS *

TODAY'S DATE *

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