To Be Completed and Signed by a Physician

MEDICAL QUESTIONNAIRE page 3 of 3

To be completed and signed by a physician.

APPLICANT First Name Middle Name Family Name Applying for Grade

Date of birth Sex: dd/ mm/ yy/

Please fill in EACH section completely. Should you be unable to complete this form at the time of application, please submit the Questionnaire with as much information as possible, with a copy of the child’s vaccination records. The completed Questionnaire must be added to the file prior to school attendance.

VACCINATIONS French law requires Diphtheria, Tetanus and Polio boosters every five (5) years. If the child’s booster for any of the above was more than five years ago, please update at the time of application or prior to school attendance at the latest.

Please note - in the U.S., Diphtheria, Tetanus and Pertussis (whooping cough) are usually given together (for example, if it is noted on your child’s vaccination records DTP, DTaP or TdaP, then the “P” is Pertussis). In the U.S. Polio is given separately as IPV (injectable) or OPV (oral). Please inform your child’s doctor that the Polio vaccination is required in France every five years as this is not the usual practice in the U.S. Pertussis is not required by French law but is highly recommended.

BCG or TB skin test: ASP requires a TB 10 unit skin test (intradermo) with the result if the student has not had the BCG.

Please complete and attach a copy of the child’s vaccination records Date of last First dose Second dose booster/vaccination Diphtheria / Diphthérie Measles/ Rougéole Tetanus / Tétanos Mumps / Oreillons

Pertussis / Coqueluche (whooping cough) Rubella / Rubéole Polio / Poliomyélite (IPV/OPV) BCG (tuberculosis) If no BCG : TB skin Date test Result : ____mm Test à la tuberculine

 I certify that this child is fit to participate fully in all strenuous exercise as part of the school program.  If any limitations to physical activity, which activities/sports are permitted:

Name of Doctor: Signature and Stamp of Doctor: Address:

Email: Telephone

41 rue Pasteur - 92210 Saint Cloud - France / www.asparis.org / Tel: +33(0)1.4112.8282 Fax : +33(0)1.4602.2390 41 rue Pasteur ; 92210 Saint Cloud ; France www.asparis.org Tel: +33(0)1.4112.8282 Fax : +33(0)1.4602.2390