Date: _______________________ Students Last Name Father Place of Employment (Father) Date Entered School Siblings: List Other

Children and Dates of Birth Mother Phone (1) First Middle (Guardian) Place of Employment (Mother) (2) (3) Date of Birth Home Address Phone Family Doctor Home Phone Emergency Phone (If unable to locate parents) (4) (5)

PAST HEALTH HISTORY Check below the illnesses your child has had: Chicken Pox Convulsions Recurrent Ear Infections Trouble with bladder or bowel control Present medications Other health or behavior problems Please explain fully on the back of this form. Asthma Allergies Physical Handicap Hospitalizations ____ ____ ____ Date Visual Acuity R. ____

PHYSICIANS EXAMINATION Wt. L. Ht. B.P. Urinalysis

Check appropriate statements below: This child has no apparent physical defects, health problems or behavior disorders. This child has the following physical defects (specify below). This child has the following health problems (specify below). This child has the following behavior disorders (specify below).

List below the specific abnormalities in the areas noted above: FAMILY HISTORY Cancer Epilepsy Diabetes Heart Disease IMMUNIZATION RECORD 1ST DPT, DTaP, or DT OPV Polio IPV HIB Hepatitis B MMR #1 MMR #2 2ND 3RD 4TH 5TH Signature of Doctor EXAMINING DENTIST REPORT Check appropriate space. 1. 2. Does the child have dental problems?
yes no no

Date

If so, have arrangements been made to correct them? Signature of Dentist

yes

Varicella

T.B. Test