MEDICAL INFORMATION

MEDICAL INFORMATION
ENFANT / CHILDREN
Nom / Surname :
Prénom / Name
Sexe
M/F
Date de naissance
Date of Birth
Nom de l'assurance maladie et accident
Medical + accident insurance details
q Pré-fleuri Insurance : Swisscare
q Other _____________________________
ANAMNESE PERSONNELLE / MEDICAL HISTORY
GROUPE SANGUIN:
ALLERGIES:
q Non q Oui
OPERATIONS:
q Non
q Oui
LESIONS ANTERIEURES:
q Non
q Oui
TRAITEMENT EN COURS:
q Non q Oui
BLOOD GROUP
___________________
___________________
___________________
ALLERGIES:
___________________
___________________
___________________
OPERATIONS:
___________________
___________________
___________________
FORMER INJURIES:
___________________
___________________
___________________
TREATMENT IN PROGRESS:
Date du vaccin / Rappel
MALADIES :
q Non
q Non
q Non
q Non
q Non
q Non
q Non
q Oui
q Oui
q Oui
q Oui
q Oui
q Oui
q Oui
REMARQUE:
q Non q Oui
Varicelle
Rougeole
Rubéole
Oreillons
Scarlatine
Hépatite
Autre
_________________
_________________
Tétanos
_________________
_________________
_________________
_________________
_________________
_________________
___________________
___________________
___________________
q No q Yes
q No
q No
q No
q Yes
q Yes
q Yes
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Last booster date
ILLNESSES :
q No
q No
q No
q No
q No
q No
q No
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
NOTICE:
q No
q Yes
Chicken pox
Measles
_________________
_________________
German measles ______________
Mumps
_________________
Scarlet fever _________________
Hepatitis
_________________
Other
_________________
Tetanus
_________________
___________________
___________________
___________________
INFORMATIONS ALIMENTAIRES / DIETARY REQUIREMENTS
REGIME ALIMENTAIRE:
SPECIAL DIET:
qSans porc
q Selon indication médicale ___________________
q Allergies ________________________________
q Autre ________________________________
qNo pork
q Medical condition ___________________________
q Allergies __________________________________
q Other __________________________________
PRE FLEURI Ecole Alpine Internationale
1885 Chesières-Villars / SUISSE Tel : +41 24 495 23 48 Fax : +41 24 495 21 25 Email : [email protected]
Internet : www.prefleuri.ch