Gb BUTUAN CITY COLLEGES SCHOOL HEALTH RECCRD Name ARE WANED Unbie A Xtale CE] Female Date of Birth LN. TG ‘Medies] History Hepa Pertigeat Family Watory ~ Adi ‘Current Health Tours YON Oo (BAdergjes: Please Hist: Medications Food, Oder ‘ory of Ansphyisxis to, Epi-Peo®: () Yes ()No y CQ Gxgrnws Autins Action Fun [] Vex [No (lease onoch) a gon Citypet Type ih B Seine disorder: Donec (Presse speci) Tndinmama_ eee Tete __%) Wst (__&) BM: {___%) BPs (Chesiv= Normal / eboormal, pleose describe.) See Ftpeenin : ee eres Bean Frecvlosic ion Corer Decal Ora) Great Serven (easy ran eager easy Visioo Ristetye sing: Righe be OO Pouural Sereecing: L] L] pa eee tees OO (Groliasi/K yphouiiLortoS) Sterropss oO Laboratory Rewlte, CI Lesd Date Dower, Ths entire examination wsenormal:}~ ffargeted TH Skin Testing: () Medstorigh rik (expoure to TD: bom, lived, travel to TD eoderaic countries; medical ek factory Test Type C)TST[JIGRA Dates Result: (JPositive [Negative Dllndeterminste/Mordertioe Referred for evslustion to: Dste____F] Low risk (oo TB test dane) The salen has lor following problems th may impact bive educaliooal expericoce: Oveion Mesring CO SpeechiLangusge Di FicetGrees Motor Deficit O trationsvsocis) §—E] Behavioe 5 One eee Recommmendtions: OR This student may participate folly ia the school programy including physical edacatioa snd competitive sports It ro, please fst restrictions: HEY Cl temsantorionssvecoagiena Po, give reason: Please attack Mamachunetly I Certificate or other complete iznnminizatioa record,Gv — BUTUAN CITY COLLEGES SCHOOL Hi IEALTH RECORD OOMale rémale Date of Binh_a2 27 Ole Bertioea Family Hinto PoStin te 02} dana (lator pau de BMhe woree?) Current ealth haves x oO WA tergee: Please list: Medications, Food. Orher, ol Aniphylaxisto______pisbra: C] vos D)Ne De eee mm Cre DP OO Soktees ayer Cite Do Bee tome o Osher (Please spec) (Current Medications (i relevant t the nudeats bealth aad salen) ore ‘order form is needed for each medication cdministered in sehoa!. Please circle those edh tered in school: @ sapere Date of Exaniaat 96) BME: %) Plrsieal Cea Tse (__%) Wet, {Cos = Rens Yotnorel pees gerbe) corral 2 eeremities ae Fee ptctoge MEENT, “Abdomen Govvr DeweslOral Geeitaia, Serreniny (eure re) (Fat aura Visioc: Risk Eye OO Mesias: Righter O O Postural Sarecins: O O Wa Lek Eye tere O O (ScolixisKyphori/Lortos=) Stemopss Laboratory Rewh: — C]Lesd, Date Donter, a The entise us senor: Date. iprobleres thst may impact bisher educatioaa) experieore: The silent has the flowin ‘ion Testing CO Speectitsogusge Di Emaionysocisd) Behavior (Otter Leet tobepeola Targeted TB Skin Testing: |) Med-lo-lligh rik (expoure fo TD: bern, lived, travel to TD rademic countries: medical ak factors): uO ies bre CITSTLI Type LJ TST LJIGRA Due; Rew: []Postive L]Neguive LJladeterminateDordertice Dy Lew risk (oo TB test don) D FicerGrmss Motor Deficitop UAN CITY COLLEGES SCHOOL HEALTH RECGRI BUT Name PRINCES LASRNI_NECOLE__Reruely COMale FyFemale Date pf Birth:_2]02/ 7007 Medics] Hatory = Y Pertinent Family History ‘erent eaiih Pears 2 x Cola Oavergics: Pease tet: Medications Food Other, Histon’ of Aouphylads to Epi-Pen®: CD] ¥ex LJNo AZ DAstma: Asma Anions C)¥es [)No (Please onach) o abies: CU Typei CL) Type Bl seaeauanser G Gouseiriecre secpy Garren Medications [if icwant © the wadrot's bralthandslen) Pleaze cinle ax cnmaund imahealy @ pene medication order form is needed for cach medication administered in school, Pinsical Pramination Date of Exaniastion:, ge 5%) Wr, {__%) BM: $6) DPE (Check Nommal/ If ctrarmal, please describe, OGroest Otes > Decrmin eo \ Feces pt Fier fe a en a Grails ——___ Screening: (earn ray (ran aw ran Vision: Riste Eye] EL) Messing: Right Lar Femur Sarecing: ED) Lei Eye eft Ear (Stoliassnkyphoni/LentosS) Sterropais (1) pol econ teats Ctet___ vie Doves ‘The entire examination vse normal lola ~alio asf Gi FEE Sie Teas: [] Med gh ik (espouse to TBs berm, Tvd vel we Trea Goamalen SSR eon): Totes Tyr TTS EO Rew: [Positive C}segative CJledeterminaiefDoniation Relened for evasion Date OF Lewis, (co TB text done) Tas salen Taste folowing probes tat may impor tnvier eluate Sarasa Oveien C5 iteoring O Speeentsasunge OD FicerGcass Motor Deficit O tnaicutsedas Behave © otter Cox ects Reommmenditions: EIN This student may participate ily fo the school program tnloalng pIpaeaT cdocatioa snd compet Po, pleat lat reateetions: espors. If N Tovmninizations are comple Geriffiate or other complete insininiCo BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD Name _ JENN: - DOMale Female Dare of Binh:_Qb/95/907 Medics} Histor nent Family Current Health Tesues ‘Aergies: Please list: Medications, Food, uber. Epi-Peo®: () Yes ()No yeaa air a ‘Aukma Action Pon [] Yer [] No (Please eroch) cies: Oi Typet DT ype Scinure disacder: 0 one (Frecse pec) Current Medications Pleese circle those edministered in sehcal: @ ssperl= ‘medication order form ix needed for each medication edministered in school. Pinvaieal Peamination Date of Exaniantioe WE Mer: 56) Ws! A. 2) BMI, -) BP: (CbseA Normal fcboormal, please dexeFee) Bim iit crm i ¥ Q Q Qo a 0 ——— a ENT. acs 0 Doar, 6 dees Geaitslia Servening: (unre asyrh ay 731 Visioo: Rigtt Eye) Mesiog: Rig tr 1 0 Postural Screesing: [) 2) Lett fe p ph teftesr CF) O) (Scolions/Kyphosis/Lortoss) Sterwops LaborstoryRewlis, C] Lead Date, OD orher. ‘The entire examination seas normal: (] Targeted TB Stun Testing: L) Medio lligh ik (expoure to TOs ber, lived, travel to TD redemic counties: medical rok ton): ht TD tes Type L) 7ST LJIGRA Dice: Rew: CJeosiive (]Negative CladeteeminsieMBerderioe Referred fer evalsation to: Date. 1 Lowe rik (oo TB tex done) Talent has tbe folowing proulemcs ist raxy impact hisvher educational experieare: Messing O Specetvtsngusge DFiceiGrms Motor Deficit TD Behavior Bi Ober mpOLLEGES SCHOOL HEALTH RECORD OMale Female Dute of Binhs_jO]21/ 2007 ‘Aree: Please lit: Medications ___ Food Oder story of Anaphylaxis to, TpiePeas: C]¥e C)Ne Q ‘Ashms: Autho Acion Plan [) Yes []No (Please erach) Bisbee: Oh typet Di Type OD seine disorter: CO Bones. er Current Medications [if inant & the Wodeats bralth and asters) Pleeze cuele hoor cdminitered in school; @ seperate ‘medication order arm is needed for cach medicetion odministered in :ehoo! Date of Exsnaastion: (__*s) Bt 3) OF: QD eeremities Onawctosic oun, Graitatis i (rand asta ears Visico: Riste tye EO Mesiog: Righe Exe EO} Pouual Scrvaing: OO Leh Eye Q teres 2 O (ScolisisK yphosivLertoss) Sterropss ui perstore Rewlts: — C]Lead Date Donec ‘The entire examination was. normal: f(cfrargeea TD Ski Tenting: C) Mediligh ik (expouce to Th; be, ved wave io TD raderie cours oneal Hk eon): TA Test Type LITSTLIGRA Dae: Rewslt: ()Posiive C}Nrpaive ClladetemninateMordertioe Referrrd for evalustion to: Dae. TD Low risk (co TB test dane) The seat has the folowing proulres hat may impact Bie educational experieeces Oveioa Meating © SpeectiL sesuage Di FiceiGrms Motor Deficit ErotiontSeds — Behavior O Otee CommerrvRreommendstions' LAY CN This stuxtent roay participate fely in tbe school program iwluding physical edocation and competitive sports. It iat restrictions:“Targeted 15 Skin Testing: LJ Medvio-Iligh risk (expoure fo TD: born, lived, travel @ TD eadercie countries: medical eak factor) pee Crs Type LITST LJ IGRA Dare Rew: C]Positive (Negative Clladetecminste/Dordedioe Ge COLLEGES SCHOGL HE: co Name Nek een Sle Female ae of Bind CRT are (os thuabiieh) 8) Bagbious = baomdoc the ( ftina/ Over oO ‘Avergice: Please st: Medications story of Aniphylaxis to Tpi-Pro®: (J Ye L)No fal rAshms: Aubms Action Pan (] Yer L]No(Please cnoch) CO Btibees Otypet OTe Q Seizure disorder: CG ovecyrrecse yey = ———— | Sees Naeem tant cues beat nnd len) Pleas ale tee eUninuieed nacfools operate medication order form is needed for each medication cdministered in school. pO Fae ination Date of Exaniaaii en 8) Wsr__(__%) BM:__f_%) BP: (Check » Neemal/ Ij etaarmal please dexerie) Lungs, Geremities Plvaical oral 5k leat erologic HEENT, oar Botrer DecealfGra ills, (rayne mrasyeran aay raz RisttyeO O Messing: Rig Lr CO) O) Postural Screening: C] C) Lek Eye teres O O (ScolimisKyphoxi/LortosS) sieropiis Liberator Rel: Led Date Dotter. ssnormal: ‘The entire exami: Referred fer evsustioat: Dste___ Low risk (oo TB test dane) Zceat fos thr faUlwing problers st raay impact Bitar educational experisore? Oveion a Mesring Speectvisnguage Di FiceGraes Motor Deficit TF Erecionstecid Behavior 1 ter student roay participate Folly Physical educstioa snd competitive sports. It Certifizate or other complete imnninization record. zo, please Fst rotcetions 'Y [JN Irerminizations are complete: Ino, give reason: Please avec poe pupil leraaiog Sg ttt plete: He, gi rep foram Tone BSED |G-lo N CITY COLLEGES SCHOOL HEALTH RECORD Name, Y CMate Zf Female Date of Birth: {722004 Matesthnnes r ——— PecinretFamivtthwery oy, f Onher, ae of Aasphylaxis to TpisPen®: (Ives Cito Asthma Action Plan [] Yes [] No (Please omtach) geen OD typet OD Type Srinure disorder: Gi once ricese geo ‘Current Medications (if relevant to the siodeat's beslih snd safety) Please ciele thoze edministered in school; @ separate foedivation order form is needed for each medicotien administered in sthoal. Pica Ramination Date of Exardaaton Tt i) wee 26) BAM: *) (Coext « Normal If ebooral peste prscribe) Gent Bice Beers én rrerotogie — ee ———— Gea ———— Dexa Grain (rare rasnein aay 750 wee isi: Ristetye OC) Mesiog: Riga tae CO] C1 Postural Serening: OO) D A Lee teter O O (Scolimisk yphoxis.orto:S) steep Laberstory Rewlis; — C]Lesd Date Dortee ‘The etire cassilaniteweacnorends (expoure to TR: bern, lived, travel (0 TD codemie countries: owdial Sk clos): ed TD Stan Testing: C] Med Yipes type TST LT ToRa Dae Rune Epomine Piveonte Pleeeneeconts oc Dates 1 Low risk (00 TB test dane) Th aralent has the folowing proulere: that raay impac hiner educational experience: (sion Hearing G SpeectyLanguage CD FicerGrmss Motor Deficit 1D tmaiionsYSecis) Behavior 7 Tene ron Resto Hart eed von ily Dr ia Certificate or other complete iennmunization rec oe ° CapeCre [ BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD ‘Medical History Name RAD. va female Date of Bisd__ OF. 00 Pertineat Fai Tinto Gir root Byeor dA Sou — Only] CMP PIE |_duareks — pexfhd Se x fs Tours ¥ OC “eiavergics: Plesse lit: Medications, Food ___ Other, c Tired: O¥e O a Asthma ction Fs DD ¥es (No (Please ertach) o Dabetes: Oty Type i QO Seinure disorder: a Onhec (Presse speci) ‘Current Medications Febealth aod wlety) Please circle thase edminisered in school; @ seperate adication erder form is needed far each medication odministered in school. Pinsical Gramination Date of Exandaaiiony, 8) West (_s) ast: (__%) BP (Check « Newmal/ Wetnarmah please dexer ' OGreest D skin B MCENT, O Deealton Scrrenin (rear ranch zs qPRieloa: Rist tye 0) essing: Righe Ear 4 Pousral Serving: £7] tSigoS tke og teres () O (ScoliisKyphou/LontosS) Sterozis Laboratory Rewite, — Lead, One Dorter The entire exsminstion wae norms): PY” weber rf ploy?™) lr wofeee / THigh ik (expoure to TD; bern lived eravelw TD eodemic Counties: aeGral Pak ctoole Result: (Positive []Negative CJlcdeterminateTordertioe Diez To tev risk (oo TO text done) Ting prone tat raay tpact hive educational expevieorer Tearing O Speectitanguage Di Ficetirass Motor Deficit DD Behavior Oy Oer ConmecrsRecomwerndusions LAY CON This student may parsicipate Fell fa the school program inclading physical educatiowand Compete spor. Tt no, please fist restrictions: °¥ CJ teumunizations are complete: Ino, give reason: Please attach Masachusetts Imumunisstion Information System Gertificate or other complete imnnunization record. __fAAMANG fees ify Heer [a0 by fat pacavciped? = pit Tro aeCl P BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD Name 2EERRcON CARL P. GusseOM COMole C)Femate Date of Binary 9, 2007- Mediesd iery : Perego —— Pectigeat Family Witony oma te ee) Ciera: Please et: Medications Food, Oe, ory of Aniphylasinto pices D va Ro Oo Bes = Auhms Acion Pan C) ¥es C)Ne(Plesss crack) o pases Oty Bi type Go Biscacc asin Oy over (Peose spec) ications {if retevant ip the wodeot's bealth and wet) Pleese cvrele thece edminutered in wool: @ separate cen Torm i needed for each medication edministered in zchoal. Q tamination Date of Examiastion: . Ea Mg: fs) Wet (__%) BSt:__ ys) (Chexk = Nommal/Ijetnormal, please scribe) gan pen tira in Tie FAiscctsic HteENT falozira Over O Dewavoei_——— A[craitstis Serrening (rane, asyeran ras (722 Visioa: Riste tye Nesing: Rigk Br OO Pouwnl Somsing: OO | ih Lek Eye tetear (SroliasisKyphosivLortoss) Steeropas LaberstoryRewlts: — C]Lesd___ te Dower ‘The entire examination was normal: GI” Targeted TD Skin Testing: () Medio igh ik (espouse to TB: ar, lived wave to TD eolevac counties ordeal Sk Loa) TH Tes Type LITSTLTIGRA Denes Result: Cpositive CNegitive CJlaeterminsteDardertioe Referred for evaluation to: Dste____D) Low risk (oo TB test dane) The erent has the folowing probes tha may impact hive educalioal paperieacr? Vion Ch itesring 1 Speeetvtaagusge CD Ficetracs Motor Deficit DD EmerionsySocis) «= Behavior DO Other CompectsMecommtndations [ot CIN Ti stent may parsipas Tay ote abe agaee including physical education snd compeiive spore It | ro. please lat restrictions: hoetiveeee TN Tronmunizations are complete: Ie, give reason: Please attach Slanachuetis Inveanization Infor Gertifizate or other complete immunization record.bole BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD Name CeDE\C “WON _k- AMALERIO. LTSiste Female Date of Birth_[™ [FxooF Medical History fp oe = Pertineat Family Hintory Carrot Health Tove YN (CB dergics: Please dist: Medications, Food, Oder Vizory of Aaiphylaxis to Tpi-Peod: C] ¥e LJNe — Asrens: Auta Action Plan L)¥er L]No Please enach) Go ebubetes Oty 0 type QO Finize disorder: o Osher (Plecte specify) (Clrrent Medic stione (U plnvant the wodlears health snd salen) Please cucle those edministered in cheal: © sxparaie medication order form is needed for each medication odiministered in zthool. fond Pizvsieal Examination Date of Exsniastion: A Zz Mg: —_—__%) Wet. (_%) Bstt;____ 98) BP, (Coget © Normal /ebnarmal, please gpxcribe.) _ roma ae Bs Ceremities a. ‘ean [axreolosic ieee Bice Cover, Dewar OGreitatis Serve (ex 9 ras (Fat aw Tan Vision: Rig EyeO Hesring: Right tr OC) Pouunsl Screcins OO Vt Left Ey’ teeter OQ O (Scolicei/K yphosie/Lardos) Steropss, Laberstory Rewlts Obese, Date Done The entire examination wax normal: EY Targeted TB Skin Tewing: () Medsiolligh risk (expouze to TB: bom, lived. travel to TB eademic countries: medical rik Lactors): FB Tes Type LI TST LJIGRA Date Resalt: C]Posiive C]Segaive (JladeierminateBordetioe Referred for evaluation to: Dste_____F Lowrisk (oo TB test done) The wolent fas te (oUowing problems that may impact hivher educations) experiroce: Oveien Hearing O Speectst anguage DFivestiress Motor Deficit J EmerionsSecial [Behavior 1 Otrer Conpeces Recommendations’ DIN Ths student raay participate folly ja the school progracy including piyaical education and competitive sports. IC aay gb ) On a a aE moBUTUAN CiT ALTH RECORD | Name _yitet_L- vAtpes, AG Wale D Female Date of Bien. PEC” 24, Foe Nese es ype hg ENE. Haale /dtnnal) EXGeerai: Please st: Medications Food One er pissn Aas Tpi-Pad: LJ Ye (No 2 Aukms Aaion Pan LJ Yer []No (Please enach) ies: CU Type! LC] T3pe it jauze disarder: one (Preece speci) (Current Medications (if relevant t the stodeat's bealih and usleny), Plesse cuvle thas cdmminaiered in school: @ 2¢perats ‘medication order form is needed for each medication odministered in school. rea Socata Ugh WOE Pinaicat ge {__*) Wee. 5) BM: 98) BP fey Gore Nermal/eboormal, Beare) Ti Fes raremiies Asn Pies. age eer tae tions Doar Dessloat eatats Serveniog eum ran rasan lo Vision: Rise Eye Messing: Righe Ear Q g Pouural Seresins: O O cubs Eye Left Ear (ScolicsisKyphosis/Lordoss) hthoheweetes A Laboratory Rewlts: OLese Date, Dover, The tise aamination wss normal: + Sprabimer Targeted TB Skin Testing [) Medsiooligh risk (expoure 10 TB: ber, lived, travel © TD eodemic countries: aedical eek eton): [GAB Tess Type: CV TST C]IGRA Dae: Rest: [Positive ()xegative CtcdeterminsteDordectioe Referred for evalustion to: ten D7 bow risk (co TB test done) ‘Glen tos the faowing problem thst ray impact histhee educational experieore: Vion easing O Speech angusge CO Fiowrress Motor Deficit Di EmaionuSecis) — Behavior Oi One we ge uoa: Pgacalch Masodbyee Tevmanjaiion lnlergpon See Gerlizate or other complete inmunizatioa reord. Pane ua Loa” a. wp (E: PrabdraaeCP BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD Name LY COMate GyFemale , Dare of Biren ya}2170—%—0 MediesI History ie ei ope tho ae¢ = 5 —— papell 7 Pectioest Family : . Mole? -aneaye (Cursen¢Tiepith Fewuee ‘Allergies: Please list: Medications, Food Other, x o Visiory of Aniphylaxiato Tpi-Peed: L] Ye LINO Qo ‘zhma: Authms Action Plan []¥es []No Please ortoch) o Q Diabetes: C}Type! Type it [ei Srinure disorder: OB omer (Piecze speci) Curren Medications (if relevant to the Mudeats bealth and waleta). Please cule Hace cdminatered tn shoal, © Eeperare ‘medication order form is needed [or exch medication edministered im acho. ion Date of Exandastivn: TT Plvsical Cram ee 52) Wet {__%) Bt: s. :) BPs (Check = Normal / if cbrormat, please describe.) , Dcromst Citas, Oexrenitice é O sin Qed Bes Otten _ FReeelesie MEENT___ ED Abdomea IS Gower 7 Desa JGrnistis seening? (ogo oy (rs as) ra inion: Riste tye ZT, Hie: ripeae BLT Powunl Serecins: OO Leh exe A tet ear APO (Scolizse/KyphorisLontosS) Sterop= ] F) Laboratory Rew: — OLesd Date Dower ‘The entize examination was normal £3} TGRA Date Result: C}positive [Negative CMadeterminsieRonlertioe Refrered for evaluation tor ste] Lee risk (00 TB test done) The Solent has tbe following problem: thet may impact hivher eduraiional expericoce: POV pil Aargrted TH Skin Testing: C) Medic Iigh ik (expouze lo TO: bern, lived, wave TD codec covatica anGcal i EO TD Tex Tyo TST Lt Oveion Messing O SprechiLsaguage Floe(Gress Motor Deficit GF EmeionsvSocia) ©) Behavior O Ghee CommnecrsRecommenditions (ON Tiki student ray participate folly | ea a ea fa platelet Re Transl are comic W gine saan Pane sacl Nlamaeheis IpanjapnTaranioa Sew Cenfglew ater compete inomndtise reed. ee oe Vo ~ 2%dene ho Booked steepGrp BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD ake hit B20 Nam WLU. A Siate D) Female ute of inn LAY (5/3007 Mee lees - on Teaieea Poa TB fe phaih day 3) Hortiad=, O11 vb Sethe ‘Cursen Halll Fees ¥ OBrien: Pleme et: Meicaions Foot Oder j ry el Anwphylasisto tps C] ven CIN : Autans Acion Pan C) ¥es CJNo (Please enoch) Oseet Otel ‘ciiele thoos edmintitsred in ehool: @ seperate deste) PF is needed for cach medication ediministered in schosl. pars Q Pivsiedl Peamination Date of Examiastion: yee es: 8) Wt (_) ove ss) oe ee aes Abdomen, Oourr, gic ees cag pawn ae ewes Visioo: Rist tye) Mesing: Rie OO Fouunl Sereoins OO & Lone Q ter O Q (ScolimisKkyphosis entos) eee Laboratory Rewlts: Obese, Date, OD other. Theentise examination wae normal: KL Targeted TD Sin Testing: [Meds igh ik (espouse o TO: bern, ned vavel to TH cadre counniea @nG&al Sk Dees TH Fes Tyee LITSTLIIGRA Dic, Resah: [Positive Negative CJinieterminsie Montetioe Referred fee evaluation to: Date) Low risk (oo TH tee done) ing problems that ray impact hives elucalonal eaperirocer Ci essing O Speeetansuage CD Ficerenes Motor Deficit 1 Behavior Oy Otter (FY (PM This stodena roay partidpate fully late school prograndtGe | BUTUAN CITY COLLEGES SCHOOL HEALTH RECORD Name 6 OMate EpFémale Due of ina, POR G1 SOU a Perineal Fame A me Datars ~ Palle 4 Mle Ube Current Healt Ey trrgies Pease SMedieasocs, Legge one $$ ei gecesi Gites Efe a Aghma: Auhns Aaion Plan L] Yer [) Ne (Please onach) oO abeies: Ci type§ CO) Type oO Seizure disorder BD ome Pieese speeib) Trent Medicatione (@ rinwant te the wodeot't bralih sad uate) Pleese circle these edministered in school; a seperate medication order form is needed for each medicetion edministered in schoo! Pie mination Date of Lxsmiastioo:_Vs Th Se) West A. Se) BMt:, J) BP:, (Check » Noomal/Iebnarmel, pleose describe) DoFoen!, et (fexremities Sa esa Einezolosic iceNT. Alsboxce Door, Dewal/Oral Geaitais Serrening: (ee TD rau (Fat awa Visioa: Rise Eye Mesos: Righe tar) C1 Pouural Screening: OO p Lelt Eye tees O O (SeolinirKyphora/LontosS) Sterropits LaberstorRawles — O)Lesd Due Dower, ‘The entire examination wae normal: EY “Fargeied TB Skin Testing: () Med-o-lligh ik (expouze to Th; tear, lined, unel to TD codewie counbien ert) Sk been): [Poe Te CTs Type LITSTLIIGRA Duce: Rewlt: C]Ponsitive C]Negative [JinteterminsteMontertioe Referred {cr evaluation to: Dae. 1 Low risk (oo TB test done) Tis pet fas tor lowing poles at ray inpae hivhee educational rape Beion jieaaeg Ly Speectstsosuage CO FicerGrers Motor Deficit 6 tmationsvSociy ©] Behaviee © Otte ro, please lit restrictions PETE Cin isssaienion are congicin ino give renn: Plone alagh Nasaphypete Ippoantaion infecting Sates Certificate or other complete immunization record. fasipas po mpTY COLLEGES SCHOGL HEALTH RECORD BUTUAN C Name Nite [i Female Date of Bieth:, fax ZF OS Medical Mixtes A ze Pertinent FamiWv1 \ Hin? Kergics: Plesse lit: Medications Foot ciory of Aniphylaxis to Epi-Peod: (Ye CJNe chma: Asthma Action Plan [] ¥e9 [No (Please cntach) sex Citypet Cl iype ‘Srinure disorder: OF ottec (Pieese speci) Curr@t HeStth Tones Other, rent Medications (Hf retee medication order form is needed for each medication edreinistered in school. Piwsiesl Cramination Date of Exardastica: Wer 8) Wet (__%) BMi_g_ 8) BP (Check = Nowmal/Ij ebnarmal, plesse describe, QD Gromst Langs OO skin, ean i MEET, Abdomen, Oxher " DewsalOAd Fi cecitais Screening: (exami ayer rg Fa Visca: Right Eye) OO Mexiog: Rik Ee 110 Pomunl Sareeins: O OO Lek E: tees ] O (Scola: Kyphosiv/Lentoss) Siemopss. or Rewits: Lead Date Dower, The entire examination was normals £3~ {lof eted TB Skin Testing: (J Med-to-Iigh risk (expoure to TD: born, lived. travel to TD roderaic countries, medical eek Bectors): Titer tee OTST Trex Type GRA Date: Reslt: (Jposiive C]Negative CJtadeterminate/Rordertioe Referred for evaluation: Date. C1 Low risk (ao TB tex dons) Ths salar has tbe following proulers thst may impac hive educational expericoce: Oveion Ieoring CO SpeechtLansuage Di Fice(tirmns Motor Deficit J tnecionsvSecis)§— ] Behaviee Gi iter CommecesMecommenditions Lape TOY CON This student may participate fully ia the school program imluding physical cducatioa and competitive sport. I fi mrminizaiions are complete: Ino, give reavaa: Please attach Massachusetts Imycyniration Information System or other complete imnmunization record. a C D plate sfc