Medical Questionnaire

Medical Questionnaire

MEDICAL QUESTIONNAIRE

Please ensure that you have read the Medicine Policy before completing this form. One form must be completed per child, please. 

It is the policy of the school that all medicine must be properly administered by a responsible adult. No pupil may have medication in their possession unless it falls into the GREEN category (see the Addendum of the Medicine Policy) or without the permission of the Sanatorium Sisters and under prescribed circumstances. 

Please complete this questionnaire regarding the medication you are happy the school administers to your child, either while they are in a hostel or while away on a school activity.  This list has been carefully drawn up by the Sanatorium, with the assistance of a doctor, and contains medicine that can be obtained over the counter and deemed safe for use. If the questionnaire is not filled in and the indemnity form is not signed, we are bound by law NOT TO treat your child. This could lead to a situation where your child has a headache, for example, and we are unable to give them any medication to relieve their pain and symptoms.

The school needs the full support and co-operation of the parents to be able to care for their children. To this end, parents are requested to complete this questionnaire and indemnity for every pupil at the beginning of each year. It is your responsibility to advise the school of any changes during the year. 

Should you have any questions regarding the medicine policy, please contact the Sanatorium at sanatorium@woodridge.co.za or 041 492 2407.

Parent Email Address Pupil Name Pupil Surname Pupil's Grade in 2024 Pupil Type Select.. Day Scholar Boarder Boarding Residence (if applicable) Select.. Carter (College girls) Founders (College girls) Kohler (College boys) Starck (College boys) Kingfisher (Prep boys) Oriole (Prep girls) Swallows (Junior boarding house) Allergies: Any health conditions: Asthmatic (please note if you are an asthmatic child and indicate YES you will be required to also complete the "Asthma Plan" Select.. Yes No Please confirm by selecting each of the category medications listed below that you WOULD ALLOW your child to take. Should any of the medications NOT be given to your child, please leave the checkbox blank and provide further details in the text box provided. There is an option to "SELECT ALL" at the top if all of the listed medications are safe and approved to administer to your child. Agree to ALL listed below Pain Medication Anti-Inflammatory Anti-nausea Anti-spasmodic Anti-diarrhea Cold and Flu medication Anti-histamine medication / cream Eye drops Cough syrup Anti-bacterial cream Anti-inflammatory gel Rescue tablets Antacid medication Mouth and throat Anti-fungal Bronchodialator CATEGORY MEDICATION APPROVAL: I hereby approve that all medications selected above can be administered to my child. Select.. Yes, I approve No, I do not approve Should any of the above listed medication categories NOT be given to your child, please provide details here: RED LISTED MEDICATION: If your child has been prescribed medicine that appears on the RED list in the school's medicine policy (attached), please complete the following information and permission form. Please ensure that you send it to the house parent and San (by ticking the staff category notice checkbox). Should your child not require any red-list medicines, please select Not Applicable from the drop-down Select.. AA Not applicable ADHD Meds e.g. Concerta, Ritalin, Strattera Anti-Anxiety e.g. Stresam, Trepiline, Esperide Anti-Depressant e.g. Lexamil, Nuzak, Prozac Prescribed analgesics e.g. Tramacet, Stilpayne Sleeping tablets e.g. Immovane, Zopivane Any medication containing codeine e.g. Myprodol Other If you indicated "Other" in the Red listed medications above, please provide details here I hereby approve that the school Doctor may prescribe medication as required by my child Select.. Yes, I agree No, I do not approve Name of any medication prescribed by your Doctor that your child is currently taking Dosage Breakfast (before meal) Breakfast (after meal) Lunch (before meal) Lunch (after meal) Supper (before meal) Supper (after meal) As prescribed Other Additional dosage notes (if applicable) Name of the Doctor who prescribed the above medication I hereby give permission to authorised / designated staff member be permitted to issue my child with medicine prescribed by a doctor that falls in the RED category according to the specifications filled in on this Indemnity Form. Select.. Yes, I approve No, I do not approve As a parent completing this questionnaire and indemnity you hereby give permission to the school to administer medication to your child. Should you select, "I do not approve" in any of the questions, the school is bound by law NOT TO treat your child and the situation could arise for example where they have a headache or other illness and we are unable to give them any medication to relieve their pain and symptoms. Select.. Yes, I agree and approve No, I do not approve Medical Aid Name Medical Aid Number Medical Aid main member Name and Surname Medical Aid Main Member ID Number submit