Name of Parent cc Guardon STATE OF FLORIDA
H
Student's
Ful Name
Address
Name of Parent cc Guardon STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES
STUDENT HEALTH EXAMINATIONS Da'e i/i /c/ct
Phone Race Sex 1--
B:Mxtue
A. HEALTH EXAMINATION Height School
Blood Pressuren
(/) NornsaluN; Abnormal -A N A COMMENT: Abnormal Findings, by number
I.Wes/wee
2. Skin/Nose
3. Head/Scalp
4. Ewa
6. Visual Acuity & L)
6. Eas
7. Auditory Acuity Ift 8 L)
8 Nose / Throat
9. Mouth. Teeth and Gums
10. Chest / Lungs
11. Heart
12. Abdomen
13. Genitals
14. Musculo-Skeleta/
IS. Neurological
16. (Vainest
17. Emotional / Mental/
Behavior Preb.)
IS. Handicap. physical/
other (Specify)
19. Activity Restrictions
(Specify)
20. Abuse. substance/
PRY:Real / emotional
21. Nutrition
22. Other
B. HEALTH HISTORY (se6ous illnesses Injuries: Cudain)
(attach narrative it additional space needed)
O. LABORATORY (as indicated)
Hemoglobln/Hematccrit Stool (O & P)
Ttberculin test: Lead Sickle Cell
NAME.
TITLE:
ADDRESS:
(Please Print) ramts v imGcNtrARP eENTSR
1 1216 Ro I Palm Beach Blvd. iss
Royal L 33411 fn'o
date
res
Autho zed Signature
MRS-II Form 3040, Me/ 91 (0bsotetes previous editions)
(Stock ember: 5744-000.3040-2)
CONFIDENTIAL irlf
3501.178-015
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