Transcription of Department of Education Student S HealtH RecoRd
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Department of Education Student S HealtH RecoRd
Student Address LabelMedical StatuS Department of EducationStudent S HealtH RecoRdNameBirthdate Parent s Name(Last) (First) (Middle Initial)Month Day YearPlease complete the following sections (CHECK IF YES)Physician, APRN, PA,ClinicCheck one box below, complete date assessment, test or x-ray was administered. Date:Date:Date:Date:Date:tubeRculoSiS evaluation/ // // /dental examination/ // /Dental Check-UpDental Check-UpPreschool: Entry DateElementary: Entry DateIntermediate/Middle: Entry DateHigh: Entry Date FemaleMale/ // // // /PHySician S examination code: n-noRmal; a-abnoRmal; c-coRRected; R-Receiving caReDate/ // /WeightGradeHeightExtremitiesScoliosisBl ood PressureSkinAbdomenLungsHeartTeethThroat NoseEyesHearingVisionNervous SystemR.
Student Address Label Medical StatuS Department of Education Student’S HealtH RecoRd Name Birthdate / / Parent’s Name (Last) (First) (Middle Initial)
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