MEDICAL INFORMATION

(TO BE FILLED BY PARENTS)

STUDENT’S NAME – Vivaan Dora

CLASS & SEC. – II-D ADMN. No. - 17968

AGE - 7 MALE / FEMALE - Male

BLOOD GROUP - Bve CONTACT No. - 9937007562

IMMUNIZATION STATUS (Please Mention ‘YES’ if Immunized otherwise Write ‘NO’)

BCG - YES MEASLES - YES

OPV - YES MMR - YES
DPT - YES TYPHOID - YES
BOOSTER FOR OPV - YES HEPATITIS B - YES
BOOSTER FOR DPT - YES ANY OTHER - YES
EYE SIGHT STATUS - YES HEIGHT – 128cm WEIGHT -27kg
ALLERGIES TO MEDICINE AND FOOD – N/A

BIRTH HISTORY COMPLICATION/HISTORY OF CHRONIC ILLNESS (If Any) N/A

Any Regular Medication – N/A

I hereby declare that my ward if fit to participate in all sports activities without any
restrictions.
FATHER’S NAME – Rupesh Kumar Dora
MOTHER’S NAME – Dora Shilpy Umapati

(TO BE FILLED BY MEDICAL ROOM INCHARGE)

 MEDICAL INFORMATION

STUDENT’S NAME -

CLASS & SEC. - ADMN. No. -

AGE - MALE / FEMALE -

BLOOD GROUP - CONTACT No. -

VISIT 1 VISIT 2 VISIT 3 VISIT 4 Parent’s Signature Medical Report