學生健康調查表

Student’s Health Record

(由家長或監護人填寫)

(To be completed by parents/guardians)

(限閱文件──所有資料只用於本校學生保健的有關事宜)

(Restricted documents—for use with students’ health-related matters only)

學生姓名：　　　　　　　　性別：　　　　　班級：　　　　　學號：　　　

(Name of student)                                  (Sex)                              (Class)              (Class number)

出生日期：　　　　　　家長／監護人姓名：　　　　　　　緊急聯絡電話：　　　　

(Date of birth)                        (Name of Parent/ Guardian)                (Contact number in case of emergency)

1.          如學生曾患有以下疾病，請在右方適當的方格內加上「ü」號及列出詳情：

If the student used to suffer or is now suffering from the following disease(s), please put a tick ‘ü’ in the appropriate box(es) on the left-hand side and describe the disease(s) in details.

2.          倘認為學生不適宜上體育課或參加任何其他類型的學校活動，請具體說明理由並隨表提交醫生證明書供校方參考。If you think your child is not suitable to participate in P.E. lessons or other school functions, please state your reason(s) together with a medical certificate for reference.

3.          其他補充資料 Other additional information：

（家長或監護人簽名）　　

Signature of Parent/ Guardian

                                           （ 日　期 ）Date