VIDYA NIKETAN
BIRLA PUBLIC SCHOOL,PILANI
Ph. 01596-242132 email : principal@[Link] web: [Link]
SCHOOL HEALTH RECORD
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General Information
Name: ........................ ........... House No:................... House…………
Father's/Guardian's Name …………………………………….
Date of Birth: ......................
Address:…………………………………………………………………
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Phone No. Office: ......................Resi:...............
Mobile: ...................................
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BOTH SIDES OF THIS FORM TO BE SUBMITTED
Name of the Student ......................................... M/F ..............Class...........................
Date of Birth ............................................ Blood Group ...........................................
Father's Name ................................. …………..Mother's Name .........................................
VACCINATIONS
Immunization Age Due Date Date
Recommended
BCG 0-1 Month
Hepatitis B At Birth
1 Month
6 Month
DPT 2 Months
3 Months
4 Months
HB 2 Months
3 Months
4 Months
Oral Polio At Births
1 Months
2 Months
3 Months
4 Months
Measles 9 Months
MMR 16 Months
DPT+OPV+HIB 18 Months
Typhoid 2 Years
Hepatitis A (2 Doses) 2 Years
Chicken Pox After age 1 year
DT - OPA 41/2 Year
BOOSTER DOSES
Typhoid (every 3 years)
TT (every 5 years)
Other Vaccines
Signature of Father ................................ Signature of Mother .............................
HEALTH HISTORY
ALLERGY TO ANY FOOD, ADHESIVE TAPE, BEE STING
Allergy What Happened How Severe Medication Taken at the
Time of Allergy
Does the child have any problem during physical activity .............................................
Signature of Father ......................... Signature of Mother ......................................
HEALTH CARD
Name of student……………………………………….. Date of examination……………………………………….
The major parameters on which annual medical checkup done are
Dental ………………………………………..
Eye ………………………………………..
General cleanliness ………………………………………..
Systemic exam ………………………………………..
Allergy if any ………………………………………..
Past/family history ………………………………………..
General appearance
Weight……………………………………….. Height ………………………………………..
Pulse……………… BP……………… Nails………………… Skin………………… Hair………………… Anemia……………
Muscle………………Skeletal system………………Knees………………Flat feet……………… Lordosis ………………
Kyphosis………………
Eye
Eye vision R/Eye……………… L/Eye……………… Squint…………Conjunctivitis……………Cornea………………
ENT
ENT check up R/ear……………… L/ear………………External Ear ……………… Middle Ear………………
Dental
Dental examination External-oral………………………….… Internal – oral…………………….…..…………
Tooth cavity……………… plaque……………… Gum inflammation………………Stains………………
Tartar………………Bad breath………….………Gum bleeding…………………Soft tissue………………
Systemic examination
Respiratory system ………………………………………..………………………………………..
Cardiovascular system ………………………………………..………………………………………..
Abdomen ………………………………………..………………………………………..
Nervous system ………………………………………..………………………………………..
Important findings ………………………………………..………………………………………..
Remarks
fit to participate in age specific physical activities
fit to participate in age specific physical activities with precaution
should not participate in age specific physical activities
Date……………………………………….. Place………………………………………..
Doctor Name and Signature ……………………………………….. ………………………………………..
