Alphera Academy

Student Health & Medication Consent

A secure two-step health record for Alphera Academy

Please complete the student health record before reviewing the Panadol (paracetamol) consent in step two.

This medical record is maintained in strict confidence and shared only on a need-to-know basis with authorized school personnel, in accordance with school policy and applicable data protection regulations.

Student Health File
Student Full Name *
Nationality *
CPR *
Residential Area *
Parent / Guardian Name *
Guardian Phone Number *
+973
Emergency Contact Number *
+973
Student's Health Center / Hospital
Known Health Conditions

Select every condition that applies to the student. Leave conditions unselected when they do not apply.

 Digestive system diseases
Sickle-cell anemia
Heart disease
Urinary tract diseases
Thalassemia
Chest / respiratory diseases
Spinal problems
G6PD deficiency
Difficulty in pronunciation
Dental problems
Endocrine diseases
Diabetes
Psychiatric illness
Allergic eczema
Epilepsy
Physical disabilities
Visual impairment
Cerebral palsy
Malnutrition
Overweight
Underweight
Hearing impairment
Iron anemia
Additional Health Information
Other diseases not listed above
Food allergies
Drug allergies
Current treatment
Consultant's Name
Assistive Devices
 Wheelchair
Hearing aids
Medical glasses
Other assistive device
Supporting Documents

Please attach a copy of the vaccination certificate. If the student has a chronic condition, also attach a consultant medical report showing the student's health status.

Does the student have a chronic condition requiring a consultant report? *
Yes
No
Vaccination Certificate *

Uploading…
Consent & Authorization
I confirm that the information provided is accurate and complete. I authorize the school clinic nurse to provide routine medical care, administer first aid, and seek emergency treatment if required.
I confirm and authorize the care described above. *
Parent / Guardian Signature (type full legal name) *
Date *

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