ALPHA HIGH SCHOOL

P.O. BOX 35136 DAR ES SALAAM

STUDENT MEDICAL INFORMATION

Name of Student: ___________________________________________

Form: __________________
SECTION I: TO BE FILLED BY THE PARENT / GUARDIAN
A: MEDICAL HISTORY
Does the child have: Yes No Explain, if any
1. Asthma: ________ _______ __________________
2. Any heart condition? ________ _______ __________________
3. Fractures? ________ _______ __________________
4. Epilepsy? ________ _______ __________________
5. Any allergies ________ _______ __________________
6. Bleeding disorders? ________ _______ __________________

B: IMMUNIZATION HISTORY
Yes No Explain, if any
Polio ________ _______ __________________
DPT ________ _______ __________________
Mumps ________ _______ __________________
BCG ________ _______ __________________
Measles ________ _______ __________________
Rubella ________ _______ __________________
Any other immunization? ______________________________________________

Parent’s / Guardian’s signature:__________________Date:___________________

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 SECTION II: TO BE FILLED BY A REGISTERED PHYSICIAN

A: PHYSICAL EXAMINATION

1. Physical Condition Normal Abnormal Explain, if any

Ear, Nose & Throat _________ ________ _______________________

Eye (vision) _________ ________ _______________________

Oral cavity, teeth _________ ________ _______________________

Lymph nodes _________ ________ _______________________

Skin _________ ________ _______________________

Neck (thyroids) _________ ________ _______________________

2. Systematic Physical Exam.

Respiration system _________ ________ _______________________

Cardiovascular system _________ ________ _______________________

Gastrointestinal system _________ ________ _______________________

Central nervous system _________ ________ _______________________

Endocrine system _________ ________ _______________________

B: LABORATORY DATA:

Hgb_________ESR_________WBC____________Urine routine_______________

C: DOCTOR’S COMMENTS AND RECOMMENDATION

__________________________________________________________________
__________________________________________________________________

_______________________________ ________________
Name & Signature of Examining Physician Date:

Name of institution/hospital __________________ Official Stamp