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~[wc:admin_header_frame]~[wc:admin_navigation_frame] ~[wc:title_student_begin]Medical Information~[wc:title_student_end]
Home Phone
~(home_phone)
~[submitbutton]
Birth Date
~(DOB)
Gender
~(Gender)
Teacher
~(Primary_Teacher)
Father
~(Father)
Daytime Phone
~(FatherdayPhone)
Mother
~(Mother)
Daytime Phone
~(Motherdayphone)
Doctor
Phone Number
ANY MEDICAL
HEALTH ISSUES
ALLERGIES
ASTHMA
Triggers
MEDICAL ALERT
(Will be viewed by teachers)
Alert Expires
(date)
(0/0/0 to never expire)
DIABETIC
Yes
No
Medications at home
Medications at school
Meds at School
Yes
No
Comunicable Diseases
Other
Consent To Treat
IMMUNIZATION
IMMUNIZATION STATUS
IC
NC
ICNP
Reason for Exemption
Medical
Religious
On Schedule
DPT/DT
(Dates)
DPT
DT
DTaP
DPT
DT
DTaP
DPT
DT
DTaP
DPT
DT
DTaP
DPT
DT
DTaP
DPT
DT
DTaP
POLIO
(Dates)
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
HIB
(Dates)
HEPATITIS B
(Dates)
VARICELLA
(Dates)
MMR
(Dates)
MEASLES
(Dates)
RUBELLA
(Dates)
MUMPS
(Dates)
OTHER IMMUNIZATIONS
Height
Weight
BMI>85%
Yes
No
LEAD ASSESMENT
LEAD SCREEN
LEAD RESULT
TB SKIN TEST
DATE
Test Results
Pos
Neg
TB X-RAY
DATE
X-Ray Results
Pos
Neg
Physical Exams (Dates)
Dental Exams (Dates)
SCREENING
VISION
EC
P
GL
FR
UC
K
P
GL
FR
UC
1
P
GL
FR
UC
2
P
GL
FR
UC
3
P
GL
FR
UC
4
P
GL
FR
UC
5
P
GL
FR
UC
6
P
GL
FR
UC
7
P
GL
FR
UC
8
P
GL
FR
UC
GLASSES
REFERRAL
VER
HEARING
EC
P
LICA
FR
UC
K
P
LICA
FR
UC
1
P
LICA
FR
UC
2
P
LICA
FR
UC
3
P
LICA
FR
UC
4
P
LICA
FR
UC
5
P
LICA
FR
UC
6
P
LICA
FR
UC
7
P
LICA
FR
UC
8
P
LICA
FR
UC
AIDE
REFERRAL
THRESHOLD
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