SCHOOL MEDICAL EXAMINATION

REVISION DATE:

1.- GENERAL DATA

NAME OF THE SCHOOL: KEY:
ADDRESS: DELEGATION:
PHONE: TURNO GRADE: SCHOOL LEVEL:
VER:
STUDENT'S NAME: SEX:
DATE OF BIRTH OR MEDICAL UNIT
"CURP" WHO ATTENDS
NAME OF PARENT OR
GUARDIAN:
ADDRESS: PHONE:

2.- FAMILY HEREDITARY HISTORY (Information provided by parent or guardian)

No. PATHOLOGY 1° 2° 3° No. PATHOLOGY 1° 2° 3°
01 TUBERCULOSIS 09 ALCOHOLISM
02 CARDIOPATHIES 10 OBESITY
03 HYPERTENSION 11 HEPATITIS
04 EPILEPSY 12 TOXICOMANIA
05 ENF. MENTAL OR NERVOUS 13 ONCOLOGICALS
06 DIABETES 14 RHEUMATICS
07 TOBACISM 15 OTHER
08 HEMOPHILIC 16 DENIES ANY PRIOR HISTORY

3.- PATHOLOGICAL PERSONAL HISTORY (Information provided by parent or guardian)

No. PATHOLOGY 1° 2° 3° No. PATHOLOGY 1° 2° 3°
01 ALLERGIES 12 CONVULSIONS
02 CARIES 13 MENINGITIS
03 RECURRENT TONSILLITIS 14 SEVERE TRAUMA
04 ORAL RESPIRATION 15 MUTILATIONS
05 PERSISTENT COUGH 16 MALFORMATIONS
06 ASMA 17 STIRBISM
07 TUBERCULOSIS 18 TOXICOMANIA
08 CARDIOPATHIES 19 ALCOHOLISM
09 FREQUENT DIARRHEA 20 TOBACISM
10 INTESTINAL PARASITOSIS 21 OTHER
11 HEPATITIS 22 DENIES ANY PRIOR HISTORY

4.- PHYSICAL EXAMINATION

1° 2° 3° 1° 2° 3° IMMUNIZATION SCHEDULE
WEIG kg kg kg SIZE: cm cm cm Complete[ ] Incomplete[ ] Void[ ]
HT:
 NUTRITIONAL STATUS
CONCEPT 1° 2° 3°
NORMAL
MALNUTRITION
LEVE
MODERATE
SEVERA
OBESITY

DIGESTIVE
CONCEPT 1° 2° 3°
NORMAL
DIARRHEA
PARASITOSIS
OTHER

VISUAL ACUITY
1° 2° 3°
O.D. 20/ 20/ 20/
O.I. 20/ 20/ 20/
CONCEPT 1° 2° 3°
NORMAL
DECREASED
USA LENSES
OTHER

DEVELOPMENTAL PROBLEMS
CONCEPT 1° 2° 3°
MALTREATMENT
PROB. CONDUCT
PROB. OF LEARNING
PROB. OF LANGUAGE

AUDITORY ACUITY
CONCEPT 1° 2° 3°
NORMAL
DECREASED
PROSTHESIS
OTHER
RIGHT EAR LEFT EAR

CARDIOVASCULAR
CONCEPT 1° 2° 3°
NORMAL
PHYSIOLOGICAL
MURMUR
ORGANIC BLOW
ARRHYTHMIA
OTHER
RHEUMATIC FEVER
 SKIN SKELETAL MUSCLE RESPIRATORY
CONCEPT 1° 2° 3° CONCEPT 1° 2° 3° CONCEPT 1° 2° 3°
NORMAL NORMAL NORMAL
PIODERMITIS ALT. OF THE UPPER LIMB. COMMON COLD
VULGAR WARTS SPINAL DEVIATION AMIG.
PEDICULOSIS VARUS VALGUS KNEE HYPERTROPHICS
PITYRIASIS ALBA FLAT FOOT OTITIS
MYCOSIS IN TREATMENT BRONCHITIS
SCABIES OTHER ASMA
OTHER OTHER

OTHER DEVICES AND SYSTEMS (diagnostic) ORAL HEALTH

CONCEPT 1° 2° 3°
ODONTOGRAM

CONCEPT 1° 2° 3°
A Healthy Teeth
PRIMARY TEETH

B Carious tooth
C Carious and obturated teeth
D Tooth filled and free of caries
E Missing Tooth
F Periodontopathies
G Malocclusion REVISION DATE

CONCEPT 1° 2° 3°
0 Healthy Teeth THIS DOCUMENT IS CURRENT
PERMANENT

1 Carious tooth OF 2012 SEAL

TEETH

2 Carious and obturated teeth INSTITUTION

3 Tooth filled and free of caries HEALTH
AS OF 2013
4 Missing Tooth
5 Periodontopathies
6 Malocclusion

CLINICALLY FIT TO ATTEND SCHOOL YES NO ( )

()
CLINICALLY FIT FOR STRENUOUS PHYSICAL ACTIVITY YES NO ( )
()

DR. MARTÍN RAMOS ALVRADO C.P. 6753390

(NAME, PROFESSIONAL LICENSE NUMBER AND SIGNATURE)

5.- DIAGNOSIS AND OBSERVATIONS (first revision) 6.- ELIGIBILITY

CONCEPT 1° 2° 3°
RECIPE
REFERENCE
S.S.P.P.D.F.
S.M.Y.U.U.D
.F.
I.S.S.S.S.T.E
.
S.E.P.
D.I.F.-D.F.
I.M.S.S.
OTHER
BLOOD GROUP RH

7.- DIAGNOSIS AND CONCLUSIONS (subsequent revisions)

DATE SCHOOL DIAGNOSTICS MEDICAL PHYSICIAN'S NAME, PROFESSIONAL LICENSE
LEVEL INSTITUTION NUMBER AND SIGNATURE