Aquinas College 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 Country

Mobile

2. ALLERGIES, FOOD INTOLERANCES & DIETARY REQUIREMENTS

Are 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 INFORMATION

Our 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 DECLARATION

I 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