Dear Parents, As part of our effort to ensure a safe and healthy learning community, a Student Medical Report (SMR) is required for all new students a

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1 Dear Parents, As part of our effort to ensure a safe and healthy learning community, a Student Medical Report (SMR) is required for all new students and returning students entering grades 1, 6 and 9. The information you provide will alert staff to any special requirements or restrictions needed for school activities. This packet should be completed and returned by the end of the first week of school. The Student Medical History (pages 2&3) is completed by parents. If there are special concerns related to any illness, please note this. If your student needs to have medications at school, please complete a Medication Administration Permission form found on the school s website. The Immunization Record (page 4) provides a list of immunizations required by our school as recommended by the World Health Organization. The Student Medical Exam (pages 5&6) must be completed by a medical practitioner. The school accepts medical exams which were completed within 1 year prior to admission. No laboratory tests are required unless the medical practitioner deems it necessary. Please note that if student health forms are not returned in the required time frame, students may be asked to stay home until they are completed. If you have any questions about school health requirements or would like information regarding hospitals and clinics that provide physical exams, please contact the school nurse. 尊敬的家长 : 作为我们尽力确保学生群体安全健康的需要, 全体新生, 以及返校生中所有升级到 1,6,9 年级的学生必须交一份学生医检报告 (Student Medical Report, SMR) 若是您的孩子需要特殊照顾或限制某些学校活动, 我们将会通知老师您所提供的信息, 且必须在开学或入学的第一周交回学生病史记录 (Student Medical History) 第 2&3 页部分需要由家长填写完成如果您有与任何疾病有关的特殊问题, 请标记若您的孩子需要在学校服用药物, 请上学校官网下载并填写药品使用许可 (Medication Administration Permission Form), 和药品一起递交学校免疫记录 (Immunization Record) 第 4 页部分上写明了我校根据世界卫生组织 (WHO) 的推荐所要求的免疫接种清单学生体检表 (Student Medical Exam) 第 5&6 页必须由医生填写完成, 学校可以接受 1 年之内做检查而完成的体检表除非医生认为有必要, 否则不需要进行任何化验请注意, 如果学生在规定时间内没有交回学生医检报告, 学生可能会被要求不能上课直到全部交齐如果您对学校的健康管理要求有疑问, 或者想知道更多提供体检的医院和诊所的相关信息等, 请随时联系校医 존경하는학부모님께 안전하고건강한학교교육환경을위한노력의일환으로, 모든신입생과 1 학년, 6 학년, 9 학년으로진급하는모든학생들은학생건강기록부 (Student Medical Report, SMR) 를제출하여야합니다. 학부모님께서알려주신정보는귀댁의자녀가특별한돌봄이나학교활동에제한이필요한경우교사에게제공될것입니다. 이패킷을모두작성하여입학혹은개학후첫주까지제출하여주십시오. 학생병력기록 (Student Medical History, 2-3 쪽 ) 부분은학부모님께서작성하여주시고, 입학 / 개학첫주간에제출하여주십시오. 어떤질병에관계된특별한염려가있다면적어주십시오. 자녀가학교에서복용해야할약품이있다면, 학교웹사이트에있는약품복용동의서 (Medication Administration Permission Form) 를작성하여약품과함께제출하여주십시오. 예방접종기록 (Immunization Record, 4 쪽 ) 부분에있는예방주사목록은세계보건기구 (WHO) 에서권장하는것을근거로본교에서요구하는예방접종입니다. 학생건강검사 (Student Medical Exam, 5-6 쪽 ) 부분은의사가작성해야하며, 최근 1 년안에검진을받고작성한것이면제출이가능합니다. 의사가필요하다고요구하지않는한별도의임상검사는필요하지않습니다. 학생건강기록부가정해진기한내에제출되지않을경우에, 제출되기전까지등교가제한될수도있음을숙지하여주시기바랍니다. 만약학생건강관련서류제출에대해서궁금한점이있거나건강검사를위한병원에대한정보등, 도움이필요하시면언제든지양호실로문의하여주십시오. 1

2 Student Medical History 学生病史记录학생병력기록 (Parents complete this page 由家长填写完成此页학부모님이작성 ) Full name 全名이름 : Age 年龄나이 : Gender 性别성별 : Birth date 出生日期생년월일 : Allergies (medications, food, environment, etc.) 有无过敏源 ( 药物 / 食物 / 环境等 ) 알레르기 ( 약, 음식, 환경등등 ): Describe the allergic reaction 请描述过敏症状알레르기반응 : List all routine prescription, over-the-counter or herbal medicines taken at home or school, and the purpose: 在家或学校定时服用的处方药, 非处方药, 中药, 以及该药服用目的 집이나학교에서규칙적으로복용하는처방약품, 일반의약품, 한약이있다면모든약의이름과복용이유를적어주십시오 : Please mark if your child has had these conditions 请标记您的孩子曾经或目前有无以下情况? 현재자녀가앓고있거나과거에병력이있는경우표시해주시기바랍니다 : Health History 健康史건강기록 Asthma or breathing problems 哮喘, 呼吸性疾病천식또는호흡기질환 Yes 有예 No 无아니오 Health History 健康史건강기록 Eczema or skin problems 湿疹, 其他皮肤疾病습진또는피부질환 Yes 有예 No 无아니오 Diabetes 糖尿病당뇨병 Chicken Pox 水痘수두 Anemia 贫血빈혈 Hepatitis 肝炎간염 Heart problems 心脏病심장질환 Nose bleeds or bleeding problems 鼻出血或血液疾病코피또는출혈 Birth defects 先天性缺陷, 畸形선천성결손 Developmental problems 发育障碍발달장애 Stomach or digestion problems 肠道消化问题위또는소화장애 Seizures, fainting 癫痫, 晕倒발작또는기절 Head injury, concussion, knocked unconscious 头部受伤, 脑震荡, 失去知觉머리부상, 뇌진탕, 의식을잃음 Migraine headaches 偏头疼편두통 Bone, muscle, spinal problems/injuries 骨骼肌脊柱问题或损伤뼈, 근육, 척추질환이나부상 Speech problems 发音问题언어장애 Vision problems or color blindness 视力问题, 色盲시각장애또는색맹 Wears glasses 戴眼镜안경착용 Wears contacts 戴隐形眼镜콘택트렌즈착용 Hearing problems, deafness 听力问题, 耳聋청각장애 Surgery or other serious injury/illness 手术病史或其他损伤 / 重病수술또는다른심각한손상 / 중병 Please give dates and explain or attach additional information if you answered yes to any of the above conditions (for example: special dietary needs, type of surgery, any long-lasting effects, etc.): 如果你对上面的问题回答有, 请填写具体时间或附加信息 ( 比如特定食品, 做过的手术, 后遗症等 ) 위의증상에대해 예 로표시한경우발병기간과상황을적어주시거나, 추가의정보들을첨부해주시기바랍니다. ( 예를 들면 : 특정식단의필요, 수술의종류, 장기적인영향등등 ): 2

3 Student Medical History 学生病史记录학생병력기록 (Parents complete this page 由家长填写完成此页학부모님이작성 ) Describe learning disabilities, emotional or behavioral problems that might affect your child s participation in school. 你的孩子是否有学习障碍, 或情绪 / 行为问题可能影响参加学校活动? 如果是, 请描述 : 자녀의학교수업참여에영향을주는학습장애혹은정서 / 행동장애를가지고있습니까? 만약그렇다면설명해주십시오 : Describe any restrictions on physical activities (i.e. PE class or sports): 你的孩子对体育活动有什么限制 ( 如体育课竞技体育 ) 吗? 如果是, 请列出 : 자녀가신체활동을하는데제한을받고있습니까 ( 예 : 체육수업, 운동경기 )? 만약그렇다면설명해주시기바랍니다. Describe your child s swimming ability 请描述您孩子的游泳能力 : 자녀의수영능력을표시해주십시오 : Beginner or none 初学者或不会초급혹은전혀못함 : Intermediate 中等중급 : Advanced 优秀상급 : For returning students, describe any health changes during the summer 对与返校生请描述暑假期间身体上的任何健康变化재학생일경우, 여름기간에어떠한건강상의변화가있다면적어주십시오 : Other useful health information: 学校应该知道的其他健康信息 : 학교가알아야할그외의건강상의정보들 : The school does not provide medication at school; parents must send any medication needed along with a Medication Administration Permission form. However, on school trips which are overnight or outside the city, teachers will have a small supply of OTC medicines available for use with parents permission. Please indicate which medicines your child is allowed to have on overnight or long-distance trips. 学校不提供任何药品 - 若孩子需要在校服用任何药品, 家长须把药物和药物使用许可表交到学校不过, 旅游或者到外地过夜等学校安排的旅行, 随行老师会携带一些非处方药品, 在家长同意的情况下, 必要时给学生使用请您选择您孩子在过夜或市外的旅行中, 允许使用的药品 학교에서는학생들에게의약품을제공하지않습니다. 만약자녀가약품을복용해야할경우, 부모님께서약품과함께약품복용허가서 (Medication Administration Permission form) 를학교로보내주셔야합니다. 그러나학생들이다른도시로현장학습을가거나숙박을해야하는경우, 교사가일반의약품을구비하여, 부모님의허락아래, 필요시에자녀에게약품을제공할것입니다. 자녀가숙박을해야하거나장거리여행중에사용을허락할약품을표시해주십시오. Yes 使用예 No 不使用아니오 Parents check yes or no for each 家长选择后并签字 각항목에학부모사용허가여부표시 : Acetaminophen (Tylenol, paracetamol) 对乙酰氨基酚 ( 泰诺, 扑热息痛 - 解热镇痛药 ) 아세트아미노펜 ( 상품명 : 타이레놀, 파라세타몰 - 진통해열제 ) *for headaches, menstrual cramps, injuries 用于头痛, 月经痛, 外伤두통, 생리통, 각종손상에사용 Ibuprofen (Advil) 布洛芬 ( 雅维 - 解热镇痛类非甾体抗炎药 ) 이부프로펜 ( 상품명애드빌 - 비스테로이드성소염진통제 ) *for headaches, menstrual cramps, injuries 用于头痛, 月经痛, 外伤두통, 생리통, 각종손상에사용 Throat lozenges or cough drops 润喉糖或止咳糖목캔디혹은기침사탕 Loperamide (Imodium) 洛哌丁胺 ( 盐酸洛哌丁胺 - 止泻药 ) 로페라미드 ( 상품명 : 이모디엄-지사제 ) *for severe diarrhea 用于腹泻심한설사에사용 Diphenhydramine (Benadryl) 苯拉海明 ( 抗过敏药 ) 디펜히드라민 ( 상품명 : 베나드릴-항히스타민제 ) *only for severe allergic emergencies 仅适用于严重过敏性突发事件심한알레르기가생긴응급상황에사용 Parent signature and date 家长签字及日期학부모서명및날짜 : 3

4 Immunization Record 疫苗记录예방접종기록 1. Attach a copy of original vaccination records. 请附上疫苗记录复印件예방접종기록사본을첨부해주세요. 2. If records are not in English, complete this form as well. 如果疫苗记录不是英文, 请完成以下表格. 기록원본이영문이아닐경우아래의예방접종기록표를작성해주세요. 3. When your child receives new immunizations, send a copy of the new records to school. 若是接种了新的疫苗, 请把该疫苗新记录的复印件交回学校 새로운예방접종을한후에는기록사본을학교에제출해주세요. Required Vaccinations 必需疫苗필수예방접종 Vaccine Name Date Given (YYYY/MM/DD) 接种日期 ( 年 / 月 / 日 ) Hepatitis B 乙肝疫苗 B 형간염 Polio - OPV (oral) 小儿麻痹症口服 Polio - IPV (injected) 小儿麻痹症注射소아마비 ( 주사형 ) DTP or Td/Tdap diphtheria, tetanus, pertussis 抗白喉, 破伤风, 百日咳 디티피 ( 디프테리아, 파상풍, 백일해 ) HIB H.Influenza type B B 型流感嗜血杆菌 b 형헤모필루스인플루엔자 PCV - Pneumococcal 肺炎球菌疫苗폐렴구균 MMR (choose type) Measles 麻疹 Rubella 风疹 Mumps 腮腺炎 MMR (3-in1) 麻腮风홍역, 볼거리, 풍진 Varicella chicken pox 水豆수두 *3 doses required for IPV, 4 doses for OPV or mixed vaccine * 5 doses for grades 1-8. If 4th dose was at age 4 or older, then 5th dose is not needed for grades 1-8. * Students must have a booster dose of Td/Tdap after age 10 and before Grade 9. See below for further information. Recommended Vaccinations 建议接种的疫苗추천예방접종 Hepatitis A 甲型肝炎 A 형간염 Japanese Encephalitis 乙型脑炎일본뇌염 Rabies 狂犬病광견병 BCG tuberculosis 卡介苗결핵 Other Vaccinations 其它疫苗기타예방접종 * 1 dose required for Pre-K to Grade 8 * 1 dose required for Pre-K & Kindergarten only * 1 dose required for Pre-K & Kindergarten only * A total of 2 doses measles, 2 doses mumps, and 1 dose rubella required before Grade 1 Meningococcal 流行性脑膜뇌척수막염 (circle type) Other 其它기타 : A A/C C ACYW (MPV4) A A/C C ACYW (MPV4) A A/C C ACYW (MPV4) A A/C C ACYW (MPV4) Other 其它기타 : ** The tetanus booster (Tdap or TD) is not available in mainland China for children older than 11 years. Please make plans to obtain this vaccine while traveling outside China. ** 请注意, 加强的破伤风疫苗 (Tdap 或 Td) 在中国大陆不给予 11 岁以上的孩子请计划带孩子出国时接种这种疫苗 ** 중국에서는 11 세이상어린이의파상풍추가접종 (Tdap 또는 TD) 이불가합니다. 고국방문시혹은중국이외의다른지역에서의이예방접종계획을세워주십시오. 4

5 Student Medical Examination( 学生体检表학생건강검사 ) (Physician or medical practitioner completes this section 由医生完成此页의사가작성 ) Full name 全名이름 : Date of exam 体检日검사일 : Gender 性别성별 : DOB 出生日期생년월일 : BP 血压혈압 : HR 心率맥박 : Height 身高키 : Weight 体重몸무게 : Normal Abnormal Notes or follow-up needed 正常정상 反常비정상 注意事项 / 评论 / 后续治疗建议소견 / 처방 / 조치 Neurological: seizures, concussion, headaches, etc 神经系统 : 癫痫, 脑震荡, 常有头痛, 等 신경계 : 발작, 뇌진탕, 두통등 Musculoskeletal: scoliosis, disabilities, etc. 肌骨骼 : 脊柱侧弯, 畸形근골격계 : 척추측만증, 신체장애 Skin & scalp 皮肤, 头肤피부 & 두피 Eyes: visual acuity, color 眼睛 : 视力, 色盲눈 : 시력, 색식별 Left 左좌 Right 右우 Ears: acuity, aids 耳朵 : 听力, 助听器귀 : 보청기등, 청력 Left 左좌 Right 右우 Speech 发音언어 Nose, throat, mouth, teeth 鼻子, 喉咙, 嘴, 牙齿 코, 목구멍, 구강, 치아 Glands, thyroid 腺体, 甲状腺내분비선, 갑상선 Heart: irregular pulse, murmur, dysrhythmia, etc. 心脏 : 心率不齐, 心脏杂音, 心律失常심장 : 불규칙한맥박, 심잡음, 부정맥등 Anemia 贫血빈혈 Lungs: asthma, SOB with activity, restrictions, etc. 肺 : 哮喘, 活动后呼吸不畅, 是否需要控制运动量폐 : 천식, 활동후호흡곤란, 제한등 Abdomen, digestion 腹部, 消化복부, 소화 Genitourinary 生殖泌尿비뇨생식기 General health habits: sleep, dental care, diet, weight 日常保健习惯 : 睡, 牙齿保健, 饮食, 营养, 肥胖일반적인건강습관 : 수면, 치아관리, 식이, 체중 Mental/behavioral health: psychiatric dx, developmental level, ADHD, psychosomatic, etc. 精神, 情绪, 行为保健 : 心理疾病, 发育程度, 多动症, 等정신, 감정, 행동건강 : 정신의학진단, 발달수준, ADHD, 잦은위통등 Physician-guided action/care plan must be attached for: asthma, diabetes, and allergies requiring an epi-pen. 针对哮喘, 糖尿病, 过敏等需要打肾上腺素注射情况, 为了在校照护学生, 请附上医师指导的处理计划참고 : 천식, 당뇨병, 그리고에피 - 펜을필요로하는알레르기는학교에서관리를위해의사의행동계획서가첨부되어야합니다. Immunizations reviewed and met minimal requirements Yes 是예 No 否아니오查对疫苗注射符合至少要求백신검토결과최소한의예방접종이충족되었습니다 Recommendation for Physical Education 医生关于参加体育项目的意见체육수업에대한의사의권고 : This child may participate in all P.E. and athletic programs without restriction Yes 是예 No 否아니오 该学生没有任何限制可以参加全部体育课和运动项目이학생은모든체육수업과스포츠행사에제한없이참여할수있습니다. Restrictions needed 需要限制参加제한사항 : Recommendation for follow-up diagnostic testing 后续诊断性检查的意见후속진단검사권장 : If any concerns need clarification, please attach pertinent records to this form. 如有任何担忧需要进一步澄清, 请在此表格中附上相关记录. 문제가있을경우이양식에관련기록을첨부해주십시오 **IMPORTANT: Tuberculosis screening on the 2 nd page must be completed as well. ** 注意 : 请填写下一页结核筛查表没有它, 这个表格是不完整的. 다음페이지에결핵검사표를완성해주세요 5

6 Tuberculosis Screening( 结核筛查表결핵검사 ) (Physician or medical practitioner completes this section 由医生完成此页의사가작성 ) Student Name 学生全名이름 : Yes 有 예 No 无 아니오 Comments 注意事项소견 Has the student had any of these symptoms recently? 最近, 孩子有过下面的症状吗? 학생이최근이런증상을보인적이있습니까? Unexplained fever for more than a week 原因不明的发烧 1 周以上일주일이상의원인을알수없는열 Unexplained weight loss 原因不明的消瘦원인을알수없는체중감소 Cough lasting over 3 weeks 三个星期以上的咳嗽 3 주이상의기침 Coughing up blood 咳血객혈 Night sweats, chills 盗汗, 恶寒야간발한, 오한 In the past year, has the student been around anyone with tuberculosis or the above symptoms? 在过去的一年, 在学生周围是否有结核病患者或有以上症状的人? 지난해, 학생이결핵에걸렸거나위증상을보인사람의근처에있었던적이있습니까? In the past year, has he/she traveled for more than a week to high-risk areas: 在过去的一年, 孩子是否去过一个星期以上结核病高发区旅游? 比如 : 지난해, 학생이다음과같은고위험지역에일주일이상여행한적이있습니까? Rural or northwest China 中国的农村或西北地区중국시골이나북서부 India 印度인도 Indonesia 印度尼西亚인도네시아 Philippines 菲律宾필리핀 African continent 非洲大陆아프리카대륙 Has the student ever had a positive TB skin test, blood test or chest x-ray? 有注射过 PPD 皮试,TB 抽血检测或胸片检查? 如果有阳性结果请标注? 학생이양성 PPD 피부검사, 결핵혈액검사또는흉부엑스레이검사를받은적이있습니까? If the student answers yes to any risk factors, the school recommends further testing: 如果学生对任何危险因素回答是, 学校建议进行进一步的检查 : 학생이위험요인에대해 " 예 " 라고답한경우, 학교는추가시험을실시할것을권고합니다 : Mantoux (PPD) skin test: for students who have not received the BCG vaccination 皮肤测试 (Mantoux/PPD): 用于没接种过卡介疫苗的学生 PPD 피부검사 : BCG 접종을하지않은학생용 IGRA/Quantiferon/T-Spot blood test: for those with BCG vaccination or who do not want the skin test 血液测试 (IGRA/Quantiferon/T-Spot): 用于接种过卡介疫苗的学生或不愿意接受皮肤测试的学生혈액검사 ((IGRA/Quantiferon/T-Spot): BCG 예방접종을받은학생또는피부검사를받지않는학생용 Chest x-ray: only if other forms of testing are unavailable or contraindicated 胸部 X- 光 : 仅用于不能进行其他检查或有禁忌的흉부엑스레이검사 : 다른형태의검사를할수없거나금지된경우 If further testing or treatment is recommended, please indicate the date, type, and result: 如果被建议进一步检查或治疗, 请注明测试日期类型和结果추가테스트가권장되었다면날짜, 유형, 결과를기록해주세요 : In my opinion, this student is free of communicable disease and may enter school. Yes 是예 我认为该学生无任何传染性疾病, 可以入学학생은전염병이없으며학교에입학할수있습니다 No 否아니오 Physician s Signature 医生签字의사성명 : Printed Name 医生姓名의사성명 : Hospital or Clinic Stamp 医院或诊所盖章진료기관도장 Phone 电话전화번호 : Address 邮箱地址이메일주소 : 6

Vaccines for Your Children - Korean

Vaccines for Your Children - Korean 어린이 for Your Children help prevent disease. Babies born in the United States may have their first vaccines right after birth. Future vaccines are given at well child check-ups with your child s doctor