MEDICAL FORM Name of the student Class: ______ Section: Roll

MEDICAL FORM
Name of the student ____________________________________
Class: ____________ Section: ________________ Roll No: _________
Date of Birth: _______________
Name of Sibling if studying in this school: _______________
Class: _________________ Section: __________ Roll No: ________
1. Parental Details:
Mother
Father
Name__________________________ Name __________________
Telephone: _____________________ Telephone: _______________
Email: __________________________ Email: ____________________
Residential address: ____________________________________
2. Person apart from parent to be contacted in case of emergency:
Name:
Relation:
Address: ___________________________________________
Contact number: ______________________________
3. Family Physician:
Name: ______________________________________
Address: (Clinic) _________________________________
Contact Number: Clinic: ____ Residence: __________ Mobile:______________
Email: ______________________________
4. Medical History
Health record
Health Problems
Allergies
Asthma
Neurological Problems
Throat infection
Diabetes
Frequent Ear infections
Hearing difficulty
Kidney / Urinary Problem
Orthopedic / Bone Problem
Skin Problem
Eye problem
Glasses / Contact lenses
Any other
Details
Blood Group: ______________
Remarks, if any
Rh Factor: _________________
Dental:
a. Has your ward been recently checked by a dentist? Yes _________ No _______
b. If yes, please furnish details: ________________________________
Recent or Past Illness
a. Has your child suffered from any serious illness in the past? ____________
b. If yes, please give details including year, diagnosis and treatement
________________________________________________________________
Other information:
Any other information relating to health of your ward, that you wish to indicate
5. Immunization record
Type of Immunization
BCG
DPT
Oral Polio
Measles
Mumps
Typhoid
1st
dose
2nd
dose
3rd
dose
4th dose
5th dose
Cholera
Hepatitis A
Hepatitis B
Tetanus Toxoid
Chickenpox
HIB
Any other
Height: _______________ Weight: _________________ Vision: ________________
CNS: ___________________
CVS: _______________________
P/A: ____________________
R/S: ________________________
Summary: Fit ________
Unfit: ______________
Comments:
Signature of Medical Examiner
Name: _____________________________
Seal and Registration No: _____________
Place: _______________________
Date:_________________________
Signature of Parent