SI14-33-H1R3 HEALTH INFORMATION 06/12/00 12.32.34
SI14-33-H1R3 HEALTH INFORMATION 06/12/00 12.32.34
STUDENT ID 5272852 it STU ID
LEGAL NAME: LAST
CURRENT SCHOOL 5101 GRADE 04 59398381. 0rTUS A SEX F ETHNIC
FIRST MIDDLE
HR SE DATE ENTERED 08
BIRTHDATE 06
MEDICAL REASON EFFECTIVE DATE / /
IMMUNIZATION: 1 EFFECTIVE DATE / /
TB TEST RESULT S
VACCINE STATUS:
DTP:
DT:
TD:
POLIO:
MMR:
MEASLES:
MUMPS:
RUBELLA:
HIB:
HEPATITIS B: EXPIRATION DATE H
APP
/ 30 / 99
/ 07 / 90
/ /
HEALTH EXAMINATION Y
07 24 90 11 12 90 02 06 91 07 17 91 08 12 94
MM DD YY MM DD YY MM DD YY MM DD YY
MM DD YY MM DD YY MM DD YY TD BOOSTER: MM DD YY
07 24 90 09 17 91 11 12 91 08 12 94
09 17 91 08 12 94
MM DD YY MM DD YY
MM DD YY MM DD YY
MM DD YY MM DD YY
MM DD YY MM DD YY MM DD YY MM DD YY
MM DD YY MM DD YY MM DD YY
SCREENING FOR HEARING PROBLEMS: Y I MEDICAL ALERT _ PH: (
SCREENING FOR VISION PROBLEMS Y CONTACT
CONFIDENTIAL MM08-S NUEVA-000020
3501.160-036
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