DELHI PUBLIC SCHOOL

NACHARAM
(ISO 9001:2008 Certified)

School Health Record

General Information

Name of the Student….………………..………… M/F ……................Class.............................. Admission No: ----------

Date of Birth: ……………………..….. Blood Group ......................................

Affix recent
Father's Name ………………............................... Mother's Name ……………...........................................
colour
Address :__________________________________________ photograph
__________________________________________ of the student
__________________________________________

Phone No. Residence : ……………........... Office: ……………………………… Mobile: ………………………….…..

_________________________________ VACCINATIONS _________________________________

Immunization Age Recommended Due Date Date of administration
BCG
Hepatitis B
DPT
HB
Oral Polio
Measles
MMR
DPT+OPV+HIB
Typhoid
Hepatitis A (2 Doses)
Chicken Pox
DT – OPA

BOOSTER DOSES___________________________
Typhoid (every 3 years) Age Recommended Due Date Date of administration
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 ……………………………………………… ..l……….

Signature of Father ………………….......................... Signature of Mother...........................................Date……………...

To be certified by a Registered Medical Practitioner

Name of the Student….………………..………… M/F ……................Class................... Admission No: ----------

Date of Birth: ……………………..….. Blood Group ......................................

Date of physical examination...................................................... Height ………............... Weight.............

B.P.............................................. Pulse …………….................. Vision L ………............... R....................
Squint.................................. Conjunctiva……………............ Cornea……............. Ear L......... R..............
Clinical Normal Recommendation
Examination
Head/Neck
Abdomen
Surgery
Serious Illness
Nails
Skin

Summary of Current Health Condition,

_____________________________________________________

Has the student had any surgery YES NO

If yes, specify
• Fit to Participate in age specific physical activity _______________________________________
• Fit to participate in age specific physical activity with precaution __________________________
______________________________________________________________________________
• Should not participate in competitive sport ___________________________________________

WHETHER THE STUDENT HAS A HISTORY OF

Congenital abnormality YES NO
Rheumatic Heart disease YES NO
Bronchial Asthma YES NO
Epilepsy YES NO
Diabetes YES NO
Hypertension YES NO
Tuberculosis YES NO
Any other disease (If yes, please give details) YES NO
---------------------------------------------------------------------------------------------------------------------------

Signature of Doctor ……………………

Name of the Doctor………………… Date :……………….

Signature of Father ...............................………………… Signature of Mother .............................