(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.
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.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.