學生姓名

：

班級：　　　　　　學號：　　　　

(Name of student)

(Class)               (Class number)

出生日期

：

性別

：

(Date of birth)

(Sex)

家長／監護人姓名

：

緊急聯絡電話

：

(Name of Parent/ Guardian)

(Contact number in case of emergency)

1.

如學生曾患有以下疾病，請列出詳情：

If the student used to suffer or is now suffering from the following disease(s), please describe the disease(s) in detail.

患病時年齡

Age of suffering

疾病資料

Details of the disease(s)

1.

六磷酸葡萄糖脫氫酶素缺乏症 G6PD

2.

哮喘 Asthma

3.

羊癇 Epilepsy

4.

高熱引致抽搐 Febrile convulsion

5.

腎病 Renal disease

6.

心臟病Heart disease

7.

糖尿病 Diabetes

8.

聽覺不健全 Hearing impairment

9.

血友病 Haemophilia

10.

貧血 Anaemia

11.

其他血病 Other haematological disease

12.

藥物敏感 Drug allergy

13.

疫苗敏感 Allergic to vaccine

14.

食物敏感 Food allergy

15.

其他敏感 Other allergy

16.

肺結核  Tuberculosis

17.

小手術 Minor operation

18.

大手術 Major operation

19.

其他 Others

2.

請細閱下列問題後，並如實回答:

（在適當方格內註明「P」號）

是Yes

否No

□

□

1.

醫生曾否說過學生的心臟有問題，以及只可進行醫生建議的體育活動？Has doctor ever said that your child has a heart condition and that he/she should only do physical activity recommended by a doctor?

□

□

2.

學生進行體育活動時是否感到胸口痛？Does your child feel pain in his/her chest when he/she joins physical activity?

□

□

3.

過去一個月內，學生曾否在沒有進行體育活動時也感到胸口痛？In the past month, did your child have chest pain when he/she was not doing physical activity?

□

□

4.

學生曾否因感到暈眩而失去平衡，或會失去知覺？Has your child lost his/her balance because of dizziness or ever lost consciousness?

□

□

5.

學生的骨骼或關節是否有毛病，且會因參與體育活而惡化？Does your child have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in joining physical activity?

□

□

6.

醫生現時是否有開血壓或心臟藥物（例如 Water Pills）給學生服用？Is doctor currently prescribing drugs (for example, water pills) for your child’s blood pressure or heart condition?

□

□

7.

是否有其他述理由令學生不應進行體育活動？Are there any other reasons that your child should not do physical activity?

□

□

8.

學生有否曾入院接受治療？如有，請詳述。

Has your child been admitted to hospital for treatment?  If yes, please specify.

3.

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 events, please state your reason(s) together with a medical certificate for reference.

4.

其他補充資料 Other additional information：

（家長或監護人簽名）

Signature of Parent/ Guardian

（ 日　期 ）Date