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 |
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