MEDICAL INFORMATION
Transcription
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: qSans porc q Selon indication médicale ___________________ q Allergies ________________________________ q Autre ________________________________ qNo 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