📄 Extracted Text (195 words)
*eel_ WARTMEC OP 1
' HEAL
STUDENT HEALTH EXAMINATIONS Date
',/
(778
Students
Full Narne Phcne APO Race Sex
Address Sktbdaa
Name di Parent a Guardian School
A. HEALTH EXAMINATION HMO —9-2/ ".1 Weght en 5 -/Zer 8100d Pressure
In NonnaleN; Abnormal-A N
t..), COMMENT: Abnormal Findings, by number
1. MOrlerance
/
2. Skin/Nose
3. Head/Scat
4. Eyes
. '
5. Visual Aarily (R 11 L) ‹.
0 Ears 5°
7. Auditory Acuity (R & LI s.,, k. '''
''•••••1
8. Ncee 1 Throat 1 ei .
i • VY 14/(/
9. lAcuth. Teeth and Gunn
10. Chest / Lungs
11. Heart
12. Altdcentm
13. Genitals and Anus
•
14. IlkscubSkeletai
15, Neurological
18. Alertness
17. Emotional / Mental/
Behreact Prob.)
1a.moneccoehysicao
other ISPecify)
19. Activity Restrict%
Mealy)
20. Abuse. substance/
cerieal / emotional
21. Nutrition
22. Other
I
B. HEALTH HISTORY Serious Messes Injuries: explain) Al bra_
(attach narrative il &Mimi space needed)
C. LABORATORY (as Indicated) da
l I
Reeloglotan/Hemalocdt Stool (0 & P)
Tuberculin test,
Lead Sickle Cell
NAME:
TITLE:
ADDRESS:
(Please Print) . •
74 7$
Authorized Signature bate •
•
(steakNtavber: 5744430.3040-2)
CONFIDENTIAL 3501.225-002
Page 1 of 1
EFTA_00075147
EFTA01248868
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EFTA01248868
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