︵FrontNameday（AtopicClass

Ｂ．Activities, which take place in dusty environments or involve contact
with animals
１．No special considerations
２．Consult and decide with guardian
３．Not allowed due to strong allergic reactions to animals
List animals （）oＢ−２．Long term control medicine（Internal medicine and externalapplication medicine）
１．Theophylline sustained releasesystem
２．Leukotriene receptor antagonist
３．Beta stimulator internal medicine
and external application medicine
４．Other（

Ｃ．Off campus activities involving overnight stays
１．No special considerations２．Consult and decide with guardian

Ｄ．Other activities, which need consideration or management（Write freely）

Submission date YrMthDay

Additional notes for school life

Ａ．State of condition （Welfare and labor scientific research group）
Ａ．Activities involving long periods Ｃ．After perspiration
１．Minor rash：Regardless of the size of the area of skin, only a slight rash exposed to UV rays and swimming １．No special considerations
２．Consult and decide withlessons
is visible.
guardian
１．No controls necessary
２．Moderate rash：The rash, which accompanies an intense irritation, is２．Consult and decide with guardian ３．（If available in school facility）
visible on less than 10% of the body.
Summer showers or baths
Y ３．Severe rash：The rash, which accompanies an intense irritation, is visible on Ｂ．Contact with animals
１．No special considerations
Ｄ．Other considerations or
e more than 10% but less than 30% of the body.
４．Very severe rash：The rash, which accompanies an intense irritation, is ２．Consult and decide with guardian controlss visible on more than 30% of the body.
３．Not allowed due to strong（Write freely）
・ ＊Minor rash：slight degree of erythema, dryness or lesions in scaly skinallergic reactions to animals＊Rash which accompanies an intense irritation： lesion which accompanies erythema, papules, seepage, lichenification orN other such ailmentsoＢ−１．Daily use externalmedicine
１．Steroid ointment
２．Tacrolimus ointment（「ProtopicⓇ」）
３．Moisturizer
４．Other（）.

★GuardianTelephone：

DEe C mt o e
a n r ★Medical Institute Contact
i t g
Medical Institute：l a es c nt cPhone：y※ May differ from stated medical instituteSubmission dateYrMthDay.

Doctor's name㊞
Medical Institute）

State of condition and medical treatment

Ｂ−２．Daily use internal
medicine
１．Antihistamine
２．Other

Ｃ．Food allergies
１．Yes
２．No

State of condition and medical treatment
Ａ．State of condition
１．Perennial allergic conjunctivitis
Y ２．Seasonal allergic conjunctivitis （Hay fever）
e ３．Vernal conjunctivitis
s ４．Atopic keratoconjunctivitis
・ ５．Other（
N Ｂ．Medical treatment
o １．Antiallergy eye drops
２．Steroid eye drops
３．Immunosurpression eye drops
４．Other（Submission dateYrMthDay.

DoctorDoctor'ss name㊞
Medical InstituteName of animalAdditional notes for school life
Ａ．Swimming lessons
１．No controls necessary
２．Consult and decide with guardian
３．Not allowed to enter pool

︵Submission dateYrMthDay.

Doctor's name㊞Medical Institute）︶

con
A
jlulnes crtgiiv
citi

attack （Write freely）
Ｂ−１．Long term control medicine（Inhaler Form）
Y １．Steroid inhaler
e ２．Long acting inhalation beta stimulant
s ３．Antiallergic drug inhalation（「IntalⓇ」）
・ ４．OtherN（）︶

dermatitisYr︼

asthmaage） School

Additional notes for school life

︵o J Cf a rp e
S a ac n th e eo s do eblS yH oe c ta i hl e et th ymth

Ａ．Exercise （P.E., club activities and others）
Ａ．Level of condition （Asthma attacks） Ｃ．Acute attack treatment
１．No controls necessary
medicine
１．Intermittent
２．Minor and ongoing
２．Consult and decide with guardian
１．Beta stimulator inhalation
３．Moderate and ongoing
２．Internal usage beta stimulator ３．Heavy exercise is not allowed
４．Serious and ongoing
Ｄ．How to deal with an acute︶form

Date of birth Yr︵Bronchial︶

Allergl yif de isg eu ai sd ea snceMale・Female

State of condition and medical treatment︻School）

Ｂ．Outdoor controls
１．No controls necessary
２．Consult and decide with guardian
Ｃ．Other considerations or controls（Write freely）
This form is based on a Japanese Society for School Health form, partially revised by the Gifu Board of Education.

︵BackSc Ah lo lo el rgl yifdeigu si eda an sce esf

Male・Female

Date of birth Yrmthdayage） School（State of condition and medical treatment

Ａ．School lunch
１．No controls necessary
２．Consult and decide with guardian

３．Wheat４．Buckwheat
Y ５．Peanuts《《《》》》））︶e》（s ６．Nuts and seeds 《
７．Crustaceans （Shrimp, Crab） 《・ ８．Fruits《》 （N ９．Fish《》 （o １０．Meats《》 （１１．Other １
１２．Other
１２ Other ２《《》》

MthDayConta Ec mt er
D ge et na ci yls

Telephone：★Medical Institute Contact
Medical institute：

Telephone：※ May differ from stated medical instituteSubmission date
YrMthDay.
㊞Medical Institute》）））））（（）

Additional notes for school life

Ａ．State of condition︵Ａ．Outdoor activities
１．No controls necessary
２．Consult and decide with guardian
Ｂ．Other considerations or controls（Write freely）

１．Perennial allergic rhinitis

fall,

Submission date
YrMthDay.

Doctor's name㊞
Medical Institutewinter︶

Y ２．Seasonal allergic conjunctivitis （Hay fever）
espring ,summer ,s Main symptoms occur in；・Ｂ．State of conditionNo １．Antihistamine drug, anti allergy drug （Internal use）

Submission date Yr★GuardianDoctor's name）

State of condition and medical treatment
S S J Cc o a rh c p eo i a ao e n tl t e e
y s deHbe oya fltthhe

C．Exercise （P.E., Club Activities andothers）
１．No controls necessary
２．Consult and decide with guardian

Ｅ．Other considerations or controls（Write freely）②Positive food tolerance test
③Positive test result for IgE antibodies or other such

Ｄ．Prescription prepared for emergency
１．Internal medicine （Antihistamine, steroid drugs）
２．Adrenaline self injection （「EpiPenⓇ」）
３．Other（conj Au ln lc et ri gv ii ctis

Ｂ．Food, classes involving foodstuffs andactivities
１．No special considerations
２．Consult and decide with guardianl
Ｄ．Off campus activities involving overnight
a Ｃ．Food allergies and basis for diagnosis Circle the number of the corresponding foodstuff and place stays
x reason 1,2 or 3 in the appropriate bracket
１．No special considerations
Place one of the following reasons for diagnosis in the２．Consideration necessary for meals andi １．Chicken eggs《》
appropriate brackets
events》
s ２．Milk and dairy produce 《①Obvious history of the condition︵︶

Yes・NoClass︼allergy

Ａ．Food allergies （Only fill in if the child has a food allergy）
１．Immediate type２．Oral allergy syndrome
３．Anaphylaxis caused by food dependency
Ｂ．State of anaphylaxis （Only fill in if child has suffered anaphylaxis in the past）
A １．Caused from food（n ２．Food dependency and exercise induced anaphylaxis
a ３．Exercise induced anaphylaxis
p ４．By insects
h ５．By drugs and medicine
y ６．Other（YrAdditional notes for school life︻Food︵︶

ormName２．Nasal spray steroid drug
３．Other（）●Do you consent to sharing the above information with the teaching faculty for use in day to day school life and emergencies?
１．I consent
２．I do not consen
Guardian signature：
This form is based on a Japanese Society for School Health form, partially revised by the Gifu Board of Education.