STUDENT MEDICAL REPORT To Be Completed by a Physician or Other Appropriate Health Care Person Child’s Name: ____________________________________________________________________________ (Last) (Middle) (First) Birth date: _________ Sex (male or female): ___________Nationality: ___________________ Name of Parent(s)/Guardian(s): ___________________________________________________Cellphone _________________ ___________________________________________________Cellphone__________________ Height: ft. in. Weight: lbs. 1. Vision Blood Pressure 2. Hearing (Gross) Normal | Abnormal R L Both Far Near With glasses? Yes/No Reading Only Yes/No Wears glasses all the time Yes/No Please check any of the following illnesses or behaviors the child has or has had: Asthma Cystic Fibrosis Bleeding Conditions Bone/Muscle Conditions Bowel Difficulties Cancer/Leukemia Chest infections Convulsions/Seizures Cerebral Palsy Dental Conditions Diabetes Ear Infections Heart Conditions Hearing Difficulties Blood Group: ___________ Meningitis ___Nervous disorders Sickle Cell Anemia Skin Conditions ___ Speech Difficulties Stomach Disorders ___Throat infections __ Allergies: (List) __________________________________________ Sickling status: ………………………………………………………………………………. Any previous hospitalizations or operations? No Yes If yes, when and for what reason? ______________________________________________________________________________ ______________________________________________________________________________ Should activities be restricted? __________________________ Immunizations (To be completed only by a doctor or other appropriate health care personnel): Record of Immunization (enter the date of EACH dose – Mo/Day/Year) Vaccine Diphtheria Measles Mumps Polio Rubella Tetanus Typhoid Whooping cough Yellow Fever Other #1 #2 #3 #4 #5 I CERTIFY THIS CHILD HAS RECEIVED THE IMMUNIZATIONS AS STATED ABOVE. Physicians Signature______________________Title_________________Date: ________________ EMERGENCY CONTACT: Name: ____________________________________________________________________ Relationship: ______________________ Phone Number: ____________________
