Medical Fitness Certificate (Part III) - …

1 123456 Eye:7 Ears:8910 DELHI PUBLIC SCHOOL, MATHURA ROAD, NEW DELHI-110003 Medical form HEALTH HISTORY ( Part- I)Date of Physical Height .. at time of Length at time of birth ..Any special Medical treatment given in first 4 weeks after birth ..Clinical ExaminationNormalRecommendationHead / NeckAbdomenSurgerySerious Illness( Diabetes etc.)NailsSkinAllergy for example : ( to any food, adhesive tape, bee sting etc.)Medication Taken at the Time of AllergyHow SevereWhat HappenedAllergy External Ear : Right :_____ Left : _____Middle Ear : Right :_____ Left : _____Flat Feet/ Lordosis/ Kyphosis(Please tick if relevant)Summary of Current Health Condition, .. : _____ORAL CAVITYGums: _____ Colour: _____ Caries:_____Teeth Occlusion: _____ Tonsils :_____ Lymph Nodes : _____Vision: _____ Right:_____ Left :_____PULSE: _____Date: Declaration by Parent ( Part - II) Signature of Parent / Guardian _____Fit to participate in physical activity Yes/ No/ with precaution ( please tick)Signature of (Official stamp with registration number)Name of the Doctor.

2 I _____ Father/ Mother / Local Guardian of _____ student of Class/ Sec. _____ Admission No. _____ hereby confirm that the above said information about my ward is correct . HEALTH HISTORY ( Part- III)Date of Birth _____ Blood Group _____Father's / Guardian's Name _____ Mother's Name _____ _____Signature of Father / Guardian _____ Signature of Mother _____Name of the Doctor .. Signature of Doctor .. (official stamp with registration number)VACCINATIONSI mmunizatonDue DateDateName of the Student _____ M/F _____ Class _____OPVM easlesHIBC hicken PoxBCGH epatitis BDTPMMRDPT + OPV + HIB Medical Fitness Certificate ( Part- IV) (to be signed by the Medical Officer , S.)

3 Mathura Road )..TT (every 5 years )Other Vaccines Typhoid (every 3 years) Certificate that I have examined Master/ Miss _____ Class / Section _____ and he/ she is medically fit/ unfit for admission in the School/ , if any_____Date : _____ Signature of Medical Officer_____ Mathura RoadBOOSTER DOSEST yphoid Hepatitis A(2 doses)Previous History of Surgery (if any).