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RIS Medical Report


									                                                                             RAINBOW INTERNATIONAL SCHOOL                                                           Page 1 of
                                                                                       MEDICAL REPORT

Student’s Name:_________________________________________________________                Date of         _____/_________/_______                                             Blood
                                                                                                                                               Male     /       Female
                        Last                  First                 Middle              Birth               mm        dd       yyyy                                         Type
Father’s Name:__________________________________________________________                                                                  Emergent Contact
                                                                                        Phone           (    )___________________
                        Last                  First                 Middle                                                               (Other than parents)
Mother’s Name :_________________________________________________________                Phone           (    )___________________
                        Last                  First                 Middle                                                              Name:___________________________________
                                                                                        Phone                                           Relation:_________________________________
Home Address                                                                            (Home)
                                                                                                        (    )___________________
                                                                                                                                        Phone: (      )______________________________
                                                                              MEDICAL HISTORY
                         Date                             Date                                Date      Current Medical Problems:
Chicken Pox                       Convulsion                      Allergies
Measles                           Meningitis                      Diabetes
Rubella                           Hepatitis                       Drug sensitivities
                                                                                                        Daily Medication          ______________________________________
Mumps                             Otitis Media                    Operations
                                                                                                        Vision Problems           ______________________________________
Whooping Cough                    Tuberculosis                    Fractures
                                                                                                        Hearing Problems          ______________________________________
Poliomyelitis                     Heart Disease                   Asthma
                                                                                                        Food Allergies ( yes/no) ______________________________________
                                DTaP                      Polio               MMR                     Hepatitis B            J. Encephalitis                Other               Other
                    1                                 1             1                             1
        Dates       2                                 2             2                             2
       (M/D/Y)      3                                 3                                           3
                    4                                 4
TB Skin Test                                                        Permission if granted for:
                                                                     a) Tylenol or Ibuprofen          yes        no        Parent Signature      _________________________________
Date      _________________________________
                                                                     b) Treatment of Illness          yes        no
                                                                                                                           Date                  _________________________________
Result     _________________________________                          c) Emergency care               yes        no
                                                                                    RAINBOW INTERNATIONAL SCHOOL                                                           Page 2 of
                                                                                             MEDICAL REPORT

                                                                                    PYSICIAN’S EXAMINATION
                                                                        Date of Birth: M/D/Y               A chest x-ray is required if the skin test result is positive.
                                                            M / F                                        Film Date          /     /      Impression: □ normal      □abnormal
          Last          First           Middle                          ------------------------        Person is free of communicable tuberculosis: □ Yes □ No
(Medical Exam must be current - within 6 months of entry date.)                                         Signature/ Agency:
(O) Normal (X) Abnormal(Comment: Specify consultation requested)                                        RIS requires evidence of immunization and Antibody for the following
Age:______                       BP:______             Hgt:______               Wgt:______              DTaP     #1             OPV    #1          MMR      #1          Hepatit B        #1
Nutritional Status:___________                                    Skin:____________                              #2                    #2                   #2                           #2
Eyes____________       Sclera________       Pupils___           Vision r.___1.___      Glasses___                #3                    #3                                                #3
Ears____________       Canals: r.____ l._____        Drums: r.___l.___      Hearing: r.___l.___                  #4                    #4
Mouth:_________        Lips:__________           Tongue:___       Pharynx:____                                   #5
Teeth:__________       Gingival:_______          Nose:___         Septum:____        Turbinate:___                                                                      Chicken pox      #1
Neck:___________       Mobility:_______          Lymph nodes:____       Thyroid: _____
Throat:_________________________         Shape:_____            Symmetry:___________
                                                                                                        I have seen evidence that these have been administered.
Lungs:_____________        Heart:______          Rate:___         Rhythm:_____       Murmur:___         Yes ___________________ No____________________
Abdomen:__________              Liver:______         Spleen:___         Hernias:______
Genital:____________       Anus:_______          Testicles: r.______ l._______                          Please be strict on immunization. For a student who has lost records, the student must
                                                                                                        have one OPV booster, and one MMR booster, along with the annual Tuberculin Skin
Spine:_____________                                                                                     Test.
Lower Extremities:____________         Range of motion:___           Development:__      Strength:___   Please administer appropriate immunization for complete records.
Upper Extremities:____________         Range of motion:___           Development:__      Strength:___   Comment___________________________________________________
Cranial Nerve:____ I-XII _______ Gait:________ Coordination:__________                                  ___________________________________________________________
Hyperactivity:_________________ Attention Deficit Disorder:_______________________                      _____________________________
Urinalysis(results):___________________________________________________________                         I certify that the student has been examined by me. This examination shows that this
Hemoglobin(result):__________________________gm/dl                                                      student is physically able to participate in physical education activities, including inter-
                                                                                                        scholastic sports, unless other wise specified above.
                                         □ Negative / □Positive
Tuberculin Skin Test: Date:___/____/_____ Result:
Physicians Signature: ___________________ Hospital:_____________________ Phone:___________________ Date:_________________

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