CARIB CHRISTIAN SCHOOL’S MEDICAL FORM
Student’s Name____________________________________________________________________________________________________
Address _______________________________________________    Birth date ________________________________________________
               _______________________________________________   Place  ________________________________________________
Father’s Name __________________________________________    Mother’s Name ___________________________________________
A.                                  HISTORY OF IMMUNIZATIONS, DISEASES, OPERATIONS, INJURIES	
IMMUNIZATION OR DISEASE	DATE OF
ILLNESS	DATE OF
IMMUNIZATION	LAST
BOOSTER		DATE	COMMENTS	
				CHICKENPOX			
DIPHTHERIA				SCARLET FEVER			
PERTUSSIS (Whooping Cough)				RHEUMATIC FEVER			
TETANUS				DIABETES			
POLIO – ORAL				ANEMIA (sickle cell)			
POLIO – SALK				PARASITES (worms-type?)			
MEASLES (Rubecio)				ALLERGY (type?)			
SMALLPOX				SEIZURES			
MUMPS				INJURY, FRACTURE			
GERMAN MEASLES (Rubella)				OPERATION			
OTHER (                                   )   				OTHER (specify)			
TUBERCULIN TEST   (type)                                        DATE                                                        NEGATIVE        POSITIVE        X-RAY?	
B.  PHYSICAL EXAMINATION                    HEIGHT                                                    WEIGHT                                           BLOOD PRESSURE	
CHECK (  ) ONLY                                    IF ABNORMAL OR NEEDS FOLLOW-UP                        PHYSICIAN’S COMMENTS, FINDINGS, TESTS (Space on other side)	
NUTRITION				
NEUROLOGIC				
ORTHOPEDIC (include arches)				
SKIN,  SCALP				
EYES	R                         L			
VISUAL ACUITY	R                         L		HAS GLASSES?                              CONTACT LENSES?	
COLOR VISION				
EARS	R                          L			
AUDITORY ACUITY	R                          L		HAS HEARING AID?	
SPEECH				
NOSE, THROAT				
MOUTH, TEETH				
GLANDS, THYROID				
HEART,  LUNGS				
ABDOMEN				
GENITALIA				
C.  LABORATORY (if needed)      HEMOGLOBIN                       GM,  HEMATOCRIT                           %    URINE                      FECES	
D.  PHYSICIAN   CHECK  () BOX.	NO	YES	PHYSICIAN’S COMMENTS (Space on other side)	
EMOTIONAL/MENTAL/BEHAVIOR PROBLEM				
HEALTH   HABITS   PROBLEM				
PHYSICAL HANDICAP == LIMITS ACTIVITY
         RESTRICTION NEEDED
         ENCOURAGE PARTICIPATION				

OTHER HANDICAP/DISABILITY
         SEIZURES				
				
ON MEDICATION (                                                 )				
FOLLOW-UP RECOMMENDED				
FOLLOW-UP COMPLETED				
This student has completed the immunizations required by the state   Yes    No    and in my opinion is free of any communicable disease and may be admitted to school   Yes    No    
Child’s Usual Physician _______________________________    Examining Physician  _________________________________________
Phone  ________________________			  Phone  _____________________    License No.  ___________________
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In my opinion this student is , is not  physically qualified to participate in athletics , driver education, other (specify) __________________________
___________________________________________________________________________ as of ______________________________________________