Health Information Form Health Information Form Student's Name First Last Please consider when completing this form that our knowing these matters could avert a serious problem, including saving your life. It is important that you outline any information that may be helpful to us in assisting you where needed.1. EMERGENCY CONTACT First Last Relationship to you Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile2. ALLERGIES, FOOD INTOLERANCES & DIETARY REQUIREMENTSAre you allergic or have a reaction to any medications i.e. penicillin, antibiotics, sulphates, morphine or other medications? If yes, please elaborate: Are you allergic to Gluten and are you Coeliac? If yes, please elaborate: Are you allergic to eggs and/or egg products? If yes, please elaborate: Are you allergic to dairy products? If yes, please elaborate: Are you allergic to crustaceans, fish and /or fish products? If yes, please elaborate: Are you allergic to nuts? If yes, please elaborate: Are you allergic to bee stings, sand flies or mosquito bites?? If yes, please elaborate: Are you allergic to anything else that affects your respiratory ability not listed above ? If yes, please detail here: Do you carry an EpiPen? If you do not carry it on you, where do you store it? Are you a Vegetarian, Vegan or have specific religious requirements? Elaborate on what food you will not eat so Chef can prepare separate meals for you: 3. HEALTH & WELLBEING INFORMATIONOur experience shows that knowing about a resident’s health history can be helpful should a problem arise. In some cases, students may not wish to indicate specific health issues in writing. If there are any health issues that you would like to discuss in confidence, please contact the College Dean. Are you Asthmatic? What medication do you use and where is it kept? Are you Diabetic? Are you Type 1 (controlled by Insulin) or Type 2 (controlled by diet) and where do you store your Insulin if Type 1? Do you currently suffer from any heart conditions and if so do you use any medications? Do you suffer from Epilepsy or have any history of seizures? If so do you use any medications and where do you store them? Do you suffer from vision or hearing loss? If so, please elaborate: Any other medical conditions or illnesses, recent surgery or other condition not listed please detail here: Do you have any diagnosed mental health problems? Please tick relevant problem(s) Anxiety Depression Bipolar Schizophrenia Eating Disorders Obsessive/Compulsive Post-Traumatic Stress Other Are you currently receiving treatment? If so , please elaborate: Are you currently taking medication? If so , please elaborate: 4. Do you wear a Medic Alert as a bracelet, necklace or tattoo on your body?Please elaborate: 5. DO YOU HAVE EMERGENCY AMBULANCE COVER (AS AMBULANCE SERVICES ARE NOT FREE IN SOUTH AUSTRALIA) ? HEALTH DECLARATIONI confirm that this information form sets out any present medical conditions and the College is entitled to rely upon this form as being complete and correct. In the event the College is not able to contact my medical practitioner for advice, I hereby authorise the College to take appropriate action in good faith and will indemnify the College for any such action undertaken. Signature of student Date student signed Signature of Parent/ Guardian if Student under 18 at time of completing this Form Date Parent/Guardian signed Δ