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Medical & Behavioral Questionnaire

Required

FUKUOKA INTERNATIONAL SCHOOL 

Applicant Information

Please enter the applicant's details.

Namerequired
First Name
Nickname (optional)
Middle (optional)
Last Name
Sexrequired
Must contain a date in D/M/YYYY format

Medical History & Allergies

Has the Applicant suffered from/experienced any of the following: (Please select)required
Does the Applicant have any of the following present medical conditions: (Please select)required
Does the Applicant have any allergies?required
Is emergency treatment needed?required
Would you like to keep the medication at school?required
Does the applicant have any food restrictions (including religious/cultural)?required
Does the Applicant have any vision difficulties?required
Does the Applicant wear contact lenses or glasses?required
Does the Applicant have any hearing difficulties?required
Does the Applicant require hearing aids?required
Which of the following vaccinations has the applicant received? (Please select)required
Attach up to 3 files at a time. File size may not exceed 10MB
No file chosen
Is the Applicant's physical movement limited in any way?required
Has the Applicant suffered from any major medical conditions in the last 2 years?required

Developmental & Psychological

Is this the first school the Applicant has attended?required
At the previous school, were there any issues relating to discipline, behavior or attendance?requiredPlease tick relevant areas.
Please tick relevant areas.
Has the Applicant had an individual support plan at a previous school?required
Attach up to 3 files at a time. File size may not exceed 10MB
No file chosen
If you have multiple files, please select and upload these at the same time.
Did the Applicant receive regular support from the school counsellor?required
Please provide the counsellor's name and contact details.
Has the Applicant received professional support* outside of the school service?required*social, emotional, development, behavioral or other
*social, emotional, development, behavioral or other
Has the Applicant had Educational Psychological testing in the past?required
As a result of the testing, were there any of the following diagnoses: (Please select)required
Attach up to 5 files at a time. File size may not exceed 10MB
No file chosen
If you have multiple files, please select and upload these at the same time.
Has the Applicant worked with a speech therapist in the past?required
Are there any other educational or social emotional needs the school should be aware of?required
Attach up to 5 files at a time. File size may not exceed 10MB
No file chosen
If you have multiple files, please select and upload these at the same time.
Has the Applicant experienced any serious/traumatic life events that we should be aware of?required

Parent Declaration & Consent

I/we declare:required
In the event that there is an accident, or the Applicant requires emergency medical treatment, and I/we (as the Applicant's parent(s)/guardian(s)), cannot be contacted:
I/we authorize FIS:required

Can we help?

If you have any issues completing this form, please contact our Admission Team.