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STAFF MEDICAL HISTORY FORM

Completing this form is mandatory. The form must be completed by the staff member prior to commencing
his/her role at the ASSET Summer Programme.

STAFF INFORMATION

STAFF NAME ________________________________ ROLE/DESIGNATION _________________________________________

HOME PHONE ________________________ DATE OF BIRTH _________________ SEX _______________

PARENT/GUARDIAN NAME(S) __________________________________________________________________________

MEDICAL EMERGENCY CONTACT INFORMATION

Primary Parent/Guardian Contact Backup Contact

(If parent/guardian listed to the left is unavailable, list the


person who would be authorised to make medical
decisions for the staff member.)

Name _____________________________________ Name _____________________________________

Relationship ______________________________ Relationship _______________________________

Home Phone ______________________________ Home Phone ______________________________

Cell Phone _________________________________ Cell Phone _________________________________

INSURANCE POLICY INFORMATION

Do you have any health/medical insurance cover?

Yes No

Please be advised that neither Educational Initiatives, nor Manipal University are liable to cover any costs
incurred due to medical visits to doctor(s)/hospital(s), medications, x-rays etc.

We shall only bear the upfront payment of the initial costs of any treatment(s), and the parent/guardian of
the above student shall be liable to reimburse Educational Initiatives for all expenses we bear for the student.

Please email a copy of your health insurance policy card to talentsearch@ei-india.com

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STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________

STAFF FIRST NAME ______________________ STAFF LAST NAME ___________________________

MEDICAL CONDITIONS

1. History of Medical conditions: Please check if you are under treatment for/deal with any of the
following:

Asthma ………………………………………………………………………………..……….. Yes No


Frequent Headaches …………………………………………………………….………. Yes No
Physical Restrictions …………………………………………………………….……….. Yes No
Diabetes ……………………………………………………………………………….………. Yes No
Fainting ……………………………………….……………………………………….………. Yes No
Seizures ………………………………………………………………………….…….……… Yes No
(If yes, please mention date of the last seizure ___________________________________________________________

Serious Eye Condition …………………………………………………………..……… Yes No


Hearing Impairment ……………………………………………………….…….……… Yes No
Surgery ………………………………………………………………………………….……… Yes No

Other Ailments
(If yes, please explain in detail) __________________________________________________________________________

__________________________________________________________________________________________________________

2. Have you received any psychological or emotional counselling? Yes No

If yes, please specify the reasons: _______________________________________________________________________

__________________________________________________________________________________________________________

3. Are you allergic to anything (medication, food, insect bites etc.? Yes No

Is the allergy life threatening? …………………………………………………………………… Yes No

Please specify the allergy ________________________________________________________________________________

What are the symptoms of the allergic reaction? _________________________________________________________

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STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________

STAFF FIRST NAME __________________________ STAFF LAST NAME ________________________________

What is the treatment for the allergic reaction? ____________________________________________________________

What should we tell the doctor? ____________________________________________________________________________

_____________________________________________________________________________________________________________

What medication can be used to treat a sudden allergic reaction? _________________________________________

Are you carrying this medication to the programme? ………………………….. Yes No

Residential Requirements (Please check the box that best describes your child’s requirements):
MEDICAL SPECIAL NEEDS

No Special Requirements

Physical Disability (short term, such as recovering from surgery, injury, etc.)

(If checked, please specify the details) __________________________________________________

Physical Disability (long term)

(if checked, please specify the details) ___________________________________________________

Other

(if checked, please specify the details) ___________________________________________________

DIETARY SPECIAL NEEDS

No Special Dietary Requirements


Diet Related Allergies

(if checked, please specify the details) __________________________________________________

Other Dietary Needs Or Restrictions

(if checked, please specify the details) __________________________________________________


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STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________


STAFF FIRST NAME __________________________ STAFF LAST NAME ________________________________

MEDICAL POLICIES

• ASSET Summer Programme staff will not prescribe, dispense or administer any medication. Staff members under
medication need to be able to administer medications on their own.
• Staff members must ensure that they are taking care of their own medication schedule. ASSET Summer
Programme will not be responsible to ensure staff members’ adherence to medication schedules.
• Please consult medication advisors regarding continuation of medication during the course of the programme.
(Note: We have observed in previous programmes that some staff members choose to avoid taking their medication
during the programme, which impacts the staff members social as well as academic adjustment to the programme.
We therefore advise you to consult your medical practitioner on the continuation of your medication during the
course of the programme.

NON-PRESCRIPTION MEDICATION

Please provide a complete list of all non-prescription medications you will be bringing along or might need to
purchase during the programme.

_______________________________________________________________________________________________________________

The medical room at the programme will have limited supply of medication such as Acetaminophen (e.g.
Paracetamol, Crocin) , Ibuprofen (e.g. Combiflam), Lomotil for diarrhoea etc. Staff members needing constant
medication are requested to bring enough supplies that can last them for the entire duration of the
programme.

Staff Member Release


I hereby release the ASSET Summer Programme, its employees and agents, from any liability that might result from my intake of
non-prescription medication during the course of the programme.

(Please check all that apply to you)


Acetaminophen (e.g. Paracetamol, Crocin) Diominic DCA for common cold

Lomotil for Diarrhoea Ibuprofen (e.g. Combiflam) Domstral for Nausea

Name of Staff Member _____________________________

Signature __________________________ Date _________________________________


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STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________

STAFF FIRST NAME ______________________ STAFF LAST NAME ___________________________

MEDICAL TREATMENT AND MEDICATION CONSENT

Please read carefully and sign. Your signature indicates that you fully understand and agree to the
authorisations and acknowledgements of your responsibilities and waiver of liabilities.

I grant my authorisation and consent to the ASSET Summer Programme staff to seek emergency diagnostic/medical
treatment or care as required by me.

I am aware of and understand the risks associated with such treatments, including (but not limited to) serious
physical injury and it is also understood that the ASSET Summer Programme is not responsible or liable for any
treatment provided.

It is also understood that the ASSET Summer Programme is not responsible for filling any insurance claims or
making payments for the emergency diagnosis and treatment. I accept full responsibility for payment of any and
every invoice or bill for treatment or care provided to me. I authorise the healthcare facility (if any) that tenders said
treatment or care to release the medical information required for payments of related insurance claims.

I hereby release the ASSET Summer Programme and its directors, officers, agents and employees from all expenses
or liabilities resulting from:
- Any emergency medical treatment or care provided to me, and/or,
- Failing to adhere to my medical schedule.

Signature _________________________________________ Print Full Name _______________________________________

Date _________________________________

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STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________

STAFF FIRST NAME ______________________ STAFF LAST NAME ___________________________

(To be filled by a MEDICAL PRACTITIONER)

PRESCRIPTION MEDICATIONS


MUST BE FILLED by a Medical Practitioner (If you are taking prescription medication)

• Medical Practitioner must list all medications prescribed to the staff member, including dosage and
schedule.

Medication: ________________________ Dosage: __________ Time: ______ a.m. _______ p.m.

Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________

Medication: ________________________ Dosage: __________ Time: ______ a.m. _______ p.m.

Staff member will take medication from dates (dd/mm/yyyy _________________ to ___________________

Medication: ________________________ Dosage: __________ Time: ______ a.m. _______ p.m.

Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________

Medication: ________________________ Dosage: __________ Time: ______ a.m. _______ p.m.

Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________

Important information (side effects, toxic reactions, drug interactions, omission reactions, potential problems
resulting from physical injury) ____________________________________________________________________________

Contraindications for medication administration: ________________________________________________________

Medical Practitioner Name ______________________________________

Medical Practitioner Signature ___________________________________ Date _______________________