INDIAN SCHOOL BOUSHER

SCHOOL HEALTH RECORD

GENERAL INFORMATION Session 2019-20
NAME: GR./ Enrollment NO:
M/F: FATHER’S/GUARDIANS NAME & ADDRESS:
DATE OF BIRTH:

PHONE NO. OFFICE:

RESI:

MOBILE:

 Name of Student_______________________________________________________

 M/F________ Grade & Div_________________

 Date of Birth_______________________________Blood Group_________________

 Father’s Name_________________________________________________________

 Mother’s Name________________________________________________________

HEALTH HISTORY
ALLERGY TO ANY FOOD, ADHESIVE TAPE, BEE STING, MEDICINE
Allergy Medication taken at time of allergy

Any other disease for which the child is on regular medication

Disease Medication Details – Name, Frequency and precautions
 Does the child have any problem during physical activity…
Clinical Examination Yes / NO Recommendation
Epilepsy/Febrile convulsion
Asthma
Surgery
Heart Diabetes/Kidney Disease
Nails
Skin

Immunizations:
1. Polio YES / NO Date:
2. DPT YES / NO Date:
3. Measles YES / NO Date:
4. DT YES / NO Date:
5. Tetanus YES / NO Date:
Operation undergone in the past, if any

Details Date Precautions if Any

Signature of Father __________________Signature of Mother______________________

To be filled by School
 Date of Physical Examination: ________________
 Height: ________________ Weight: _____________
 Vision L: __________ R: ____________ Squint: ________
 Ear L: ____________ R: _______________
 Summary of Current Health Condition: _________________________

Fit to participate in age specific activity Yes / NO

Signature of School Staff Nurse: ______________________