MEDICAL FITNESS
Name of the Student
Address
Birthdate
Sex
Age
Class
Weight
Height
Blood Group
Overall Health: Sound/Weak
Whether suffering from any
Chronic diseases?
Any hereditary problems?
If yes, specify
Any allergies/reaction
If Yes, specify
Whether completely vaccinated?
If No, Specify reasons
Whether acquired any infections/
Diseases?
If Yes, specify
Name, address & Tel. No. of
Family Doctor 		: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________

I hereby submit this report to my utmost knowledge.

Date Signature of Parent

 
Signature of Family Doctor with Stamp Signature of Principal
(If the child suffers from any disease, Please fill up the correct information regarding it)