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Medical Form

Medical Form

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Published by Taktse Window
Taktse Medical Form to be submitted at time of Admission and when any important changes require the school's notice.
Taktse Medical Form to be submitted at time of Admission and when any important changes require the school's notice.

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Categories:Types, School Work
Published by: Taktse Window on Aug 09, 2013
Copyright:Attribution Non-commercial

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11/23/2013

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Taktse International School

Medical Form
Name of Student: Name of Parents: Address: Home Ph: Date: Cell Ph: Emergency Ph: Signature of Doctor: Date:

Name of Doctor: Address of Doctor: Doctor Ph: Please Attach Doctor’s Stationery Immunizations BCG DPT OPV Hepatitis B Measles Dates Given

Other Examinations Examinations Date Given Eyes Ear Throat Chest CVS Hernia Skin Joints Genital Abdomen Blood Type:

Age Specific Dates Given DPT Booster (1.5 Years Old) DT Booster (2nd 4-5 Years Old) TT (10 Years Old) Optional Vaccines (Age to Be Given) Dates Chicken Pox (12 Months) Hepatitis A (24 Months) Typhoid (24 Months) HIB Meningitis

Examination Report: Please describe the following. If there is not enough space please attach additional sheets of paper. Past Illnesses, Allergies, Surgeries: Family History of Illness: History of Allergies (medicines, food, etc): History of Tuberculosis: Does this student have any medical problems? Does this student take any medicine? Please give your doctor’s Ph. # and 3 family #’s to be called in case of an Emergency: Doctor: Family Member 1:Name: Family Member 2:Name: Family Member 3:Name: Relation: Relation: Relation: Ph: Ph: Ph: Ph:

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