Student Admission Form: Children of Determination

Student's Full Name *

Student's DOB

Gender

MaleFemale

Student's Nationality

Address

Parent/Guardian Information

Father's Name

Father's Contact Number

Father's Email

Father's Occupation

Mother's Name

Mother's Contact Number

Mother's Email

Mother's Occupation

Kindly add the details of a person who can be contacted for any emergency, in case the parent/guardian did not attend to the call.

Other Person Name

Other Person Contact Number

Relation

Dose the Child have any?
AllergiesUnusual Health Problems or Special Needs (e.g. Diabetes, Asthma, ADHD)Dietary RestrictionsRegular Medication Given

In case of emergency may we take your Child to Bahria International Hospital Rawalpindi?
YesNo

If you wish to give permission for the nurse to give the basic medication to your child at School
Paracetamol (Tylenol)AntacidDecongestantIbuprofenThroat lozengesAny other medication that Doctor may decide

To be filled by a Child Specialist or Child's Regular Physician

Vision Screening

Right Eye 20/

Left Eye 20/

Hearing Screening

Right Ear

Left Ear

General Physical Examination

General appearance

Nutritional Status

Posture / Motor Behaviour

Ear Nose Throat

Heart

Lungs

Abdomen

Genitalia (Tanner Stage)

Bones, Joints, Muscles

Neurological

Skin

Other

Estimated Developmental Level

Summary of abnormal findings, if any

Medical Diagnoses

Assessment

Recommendations and referrals made, if any:

Local Physician Name

Physician Contact Number

Physician Address

Immunization Record

Vaccine Type

DPT (1st dose)

DPT (2nd dose)

DPT (3rd dose)

DPT (4th dose)

DPT (1st dose booster)

DPT (2nd dose booster)

Country of Immunization

Diphtheria (1st dose)

Diphtheria (2nd dose)

Diphtheria (3rd dose)

Diphtheria (4th dose)

Diphtheria (1st dose booster)

Diphtheria (2nd dose booster)

Country of Immunization

Pertussis (1st dose)

Pertussis (2nd dose)

Pertussis (3rd dose)

Pertussis (4th dose)

Pertussis (1st dose booster)

Pertussis (2nd dose booster)

Country of Immunization

Tetanus (1st dose)

Tetanus (2nd dose)

Tetanus (3rd dose)

Tetanus (4th dose)

Tetanus (1st dose booster)

Tetanus (2nd dose booster)

Country of Immunization

Polio (1st dose)

Polio (2nd dose)

Polio (3rd dose)

Polio (4th dose)

Polio (1st dose booster)

Polio (2nd dose booster)

Country of Immunization

MMR (1st dose)

MMR (2nd dose)

MMR (3rd dose)

MMR (4th dose)

MMR (1st dose booster)

MMR (2nd dose booster)

Country of Immunization

BCG/TYNE (1st dose)

BCG/TYNE (2nd dose)

BCG/TYNE (3rd dose)

BCG/TYNE (4th dose)

BCG/TYNE (1st dose booster)

BCG/TYNE (2nd dose booster)

Country of Immunization

Hepatitis B (1st dose)

Hepatitis B (2nd dose)

Hepatitis B (3rd dose)

Hepatitis B (4th dose)

Hepatitis B (1st dose booster)

Hepatitis B (2nd dose booster)

Country of Immunization

Hepatitis A (1st dose)

Hepatitis A (2nd dose)

Hepatitis A (3rd dose)

Hepatitis A (4th dose)

Hepatitis A (1st dose booster)

Hepatitis A (2nd dose booster)

Country of Immunization

Rabies (1st dose)

Rabies (2nd dose)

Rabies (3rd dose)

Rabies (4th dose)

Rabies (1st dose booster)

Rabies (2nd dose booster)

Country of Immunization

Typhoid (1st dose)

Typhoid (2nd dose)

Typhoid (3rd dose)

Typhoid (4th dose)

Typhoid (1st dose booster)

Typhoid (2nd dose booster)

Country of Immunization

Meningitis (1st dose)

Meningitis (2nd dose)

Meningitis (3rd dose)

Meningitis (4th dose)

Meningitis (1st dose booster)

Meningitis (2nd dose booster)

Country of Immunization