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PUSHPANJALI COLLEGE OF NURSING

AGRA, UP
SCHOOL HEALTH ASSESSMENT FORM
Name of the Village/Area:

School :

Name of the student :

Age :

Gender :

No.of Brothers :

No. Of Sisters :

Date of Assessment :

PHYSICAL ASSESSMENT
Assessment Findings
Head
Face
Eyes/Vision
Ears
Nose
Mouth
Dental
Neck
Chest
Abdomen
Back
Extremities
Bowel Functions
Bladder Functions
Height in Cms
Weight in kgs
BMI

Any sign of Congenital abnormalities:..............................................................................

Any signs Protein Energy Malnutrition:.............................................................................

Sign of the student:

Sign of the supervisor:

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