Thomas A. Wildey School Medical Evaluation Form

ADVERTISEMENT

Please return to:
Clermont County Board of DD
Thomas A. Wildey School
2040 US Highway 50
Batavia, OH 45103
(513) 732-7015
(513) 732-4950 Fax
Thomas A. Wildey School
Medical Evaluation Form
Patient’s Name: _____________________________ Date of Examination: ______________
Sex:
Male
Female
Date of Birth: ______________________
PATIENT HISTORY
Diagnosis: _______________________________________________________________________________
Past Injuries, Surgeries, Hospitalizations, Recurring Medical Problems: _______________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Allergies and Skin Problems:__________________________________________________________________
Seizures (Type and Frequency): _______________________________________________________________
Current medication schedule: _________________________________________________________________
_________________________________________________________________________________________
TB Skin Test and X-Ray:
Negative
Positive
Date: __________ Type: ____________
IMMUNIZATION AND DATES
Physician may attach copy of the immunization records.
DTP/Td
POLIO
MMR
HIB
HEP B
VARICELLA
If the child has not received all the immunizations as required, please indicate the medical reasons
why these were deleted: ____________________________________________________________
medical evaluation form
white 5/2013

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2