Microsoft word - student health record 2008-2009.doc


Full Name: _____________________________________ Parent/Guardian Name: ____________________________________
Birthdate: ___ / ___ / ___ Home Phone: _________________ e-mail address: ____________________________________

Work Phone (Father): _____________________ (Mother): ___________________ (Step-Parent): _____________________
Physician’s Name: _______________________________ Telephone Number: ______________________________________
PARENTAL SIGNATURE : ____________________________________________________________________________
Student must be covered by MEDICAL INSURANCE to participate.

Insurance Policy Holder’s Name: ___________________________ Insurance Company: _______________________________
Policy #: _______________ Is student covered by medical insurance? Yes :  No : 
Dentist’s Name: ______________________________ Telephone Number: __________________
Dental Insurance Company: _______________________ Policy # ______________
Have any of your close relatives (parents, siblings) suffered serious diseases such as, but not limited to, cancer, heart disease,
diabetes, mental disorder, or epilepsy?
Please explain: __________________________________________________________________________________________
Have you ever been hospitalized, seriously injured, or operated upon? ____________________________________________________________________________ Do you have a problem with allergies or allergic reactions to foods, drugs, or other agents? ____________________________________________________________________________ Have you had a chronic illness that required prolonged medical care? Do you take daily medication at present?  ____________________________________________________________________________ Have you ever suffered from an emotional illness, bad nerves, or been under psychiatric care? ____________________________________________________________________________ Do you need emergency medication in school? (If yes, please list drug’s name and reason for dispensing)
SYMPTOM REVIEW (To be filled out by student) - In the past year, have you:
1. Had frequent colds, chronic coughs, or ear troubles?   7. Had loss of appetite or unexpected weight loss?  2. Had severe headaches, dizzy spells, or blackouts?  8. Worried alot? Are there problems at home?   3. Ever fainted after participating in a sports event? 4. Are you often tired, weak, fatigued, or short of breath?  5. Do you have frequent abdominal pains, or diarrhea?  6. Have you noticed blood or painful urination? 12. Is there anything concerning your health you would like to discuss with the Doctor? (Please discuss)
#12. Discussion : _________________________________________________________________________
Please explain any “yes” answers (except #10), please specify number.
MEDICAL EXAMINATION (To be filled out by a Medical Practicioner)
1. Does the child have a diagnosed medical condition?
If yes, please explain _____________________________________________________________ 2. Does the child have a health condition which may require EMERGENCY ACTION while he is at school? (e.g. seizure, allergy, asthma, bleeding problem, diabetes, heart problem) If yes, please explain _____________________________________________________________ 3. Are there any abnormal findings on evaluation for concern? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. If yes, please indicate : ___________________________________________________________ If yes, please specify nature and duration : ___________________________________________ 8. Please specify below any over the counter medication that can be dispensed to the child. (Discuss with Parent/Guardian) Medication Yes No Medication Yes No
M.D. Signature: ____________________________________________ Date: ___________________


Guideline vulvovaginal candidosis (2010) of the german society for gynecology and obstetrics, the working group for infections and infectimmunology in gynecology and obstetrics, the german society of dermatology, the board of german dermatologists and the german speaking mycological society

Diagnosis,Therapy and Prophylaxis of Fungal DiseasesGuideline vulvovaginal candidosis (2010) of the german society forgynecology and obstetrics, the working group for infections andinfectimmunology in gynecology and obstetrics, the german societyof dermatology, the board of german dermatologists and the germanspeaking mycological societyProf. Dr. med. Werner Mendling, Vivantes – Klinikum im Fr

Microsoft word - red yeast rice.doc

FROM: The Doctors’ Desk May 2010 Red Yeast Rice: Is it a reasonable alternative to statins to lower cholesterol or a risky unregulated natural substance? Some patients are attracted to idea of lowering their cholesterol with natural methods. This includes a prudent diet, regular exercise and taking dietary supplements like red yeast rice (RYR). Red yeast rice is marketed as a na

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