EFTA01247937.pdf

Fro LFX0 CUMULATIVE HEALTH RECORD ANNUAL PHYSICAL INSPECTION FULL NAME DATE OF BIRTH FIRST MIDDLE SEX CHECK DISEASES HAD (,/) RHEUMATIC FEVER ( ) DIPHTHERIA ( ) SCARLET FEVER( ) SMALL PDX ( ) PERTUSSIS (WHOOPING COUGH) ( ) CHICKEN PDX ( ) MUMPS ( ) MEASELS ( ) CODE: NO DEFECTO Ogle X DEFECT CORRECTED DEFECT BEING TREATED TD En it t-c.c.I reNE-S.qfr- YEAR I -s-% un' 'II I 19 19 19 19 19 19 19 19 19 19 19 19 19 HEIGHT Z COmil uret. WEIGHT 0.• •••600.0 a 7 VISION RIGHT O 9 4 Pj VISION LEFT 0 i es) HEARING RIGHT 60 O c HEARING LEFT CI Z TEETH THROAT O Q41 tftlrheradiseleSMob SCOUOSIS I•somPOOM OXAMITMAM ant 0 POSTURE SPEECH PARENTS/GUARDIAN NOTIFIED ( ) • EXAM or PHYSICIAN) (Yi. 9-/0-4:1„. EXAMABY DENTIST) ( )• BMIUMPATION HISTORY POMO REMARKS INA MO DAY V MO DAY VA 1 S ICIS IC Z . 134 I A I I- lc- A, It- io-8? it, C:h4c4'.4?..att;....f. m I- I- S. 2 I- t- VI? ii. e . kq lAqt.I;n st)) .,i;:c k. `"°,-. -Age 4 1- 1.44 - tit c- I - PI `WS ..a kla i* ' ir.l'h , t“,,,(..h_ D Ce I '" t 1 1.-1 - 90 ' S : '''-• -4, 1:44.P i lag s . ,:i...9(3/5 q•k4i.- .. ..,, A ' '' I 0 -.IL 9.-n -cm.. ' _ .4“- =typtiimral.s,:_kcCIV"), '41. n".5 . ','' ; ‘ • k J I: • (*When nn mernani MMa0 00009 3501.178-008 CONFIDENTIAL Page 1 of I EFTA 00071439 EFTA01247937