EFTA01247278.pdf

SI14-33-H1R3 HEALTH INFORMATION 06/12/00 12.32.34 STUDENT ID 5272852 it STU ID 59398381.0 rTUS A SEX F ETHNIC H LEGAL NAME: LAST FIRST MIDDLE APP CURRENT SCHOOL 5101 GRADE 04 HR SE DATE ENTERED 08 / 30 / 99 BIRTHDATE 06 / 07 / 90 MEDICAL REASON EFFECTIVE DATE / / IMMUNIZATION: 1 EFFECTIVE DATE / / EXPIRATION DATE / / TB TEST RESULT S HEALTH EXAMINATION Y VACCINE STATUS: DTP: 07 24 90 11 12 90 02 06 91 07 17 91 08 12 94 DT: MM DD YY MM DD YY MM DD YY MM DD YY TD: MM DD YY MM DD YY MM DD YY TD BOOSTER: MM DD YY POLIO: 07 24 90 09 17 91 11 12 91 08 12 94 MMR: 09 17 91 08 12 94 MEASLES: MM DD YY MM DD YY MUMPS: MM DD YY MM DD YY RUBELLA: MM DD YY MM DD YY HIB: MM DD YY MM DD YY MM DD YY MM DD YY HEPATITIS B: MM DD YY MM DD YY MM DD YY SCREENING FOR HEARING PROBLEMS: Y I MEDICAL ALERT _ PH: ( SCREENING FOR VISION PROBLEMS Y CONTACT MM08-S NUEVA-000020 3501.160-036 CONFIDENTIAL Page I of I EFTA_00069504 EFTA01247278