Delhi Public School, Mathura Road, New Delhi-110003: Health History (Part-I)

DELHI PUBLIC SCHOOL, MATHURA ROAD, NEW DELHI-110003
MEDICAL FORM
HEALTH HISTORY ( Part- I)
1 Date of Physical examination....................................... Height .................. Weight................................
Weight at time of birth.............................................. Length at time of birth ......................................
Any special medical treatment given in first 4 weeks after birth

......................................................................................................................................................................................................
................................................................................................................................................................................
2 Clinical Examination Normal Recommendation
Head / Neck
Abdomen
Surgery
Serious Illness
( e.g. Diabetes etc.)
Nails
Skin
3 Allergy for example : ( to any food, adhesive tape, bee sting etc.)
Allergy What Happened How Severe Medication Taken at the Time of Allergy
4 PULSE: ______________ B.P. : __________________

5 ORAL CAVITY Gums: ___________ Colour: _____________ Caries:________________
Teeth Occlusion: ________ Tonsils :________ Lymph Nodes : __________
6 Eye: Vision: ____________ Right:_____________ Left :____________
7 Ears: External Ear : Right :_____________ Left : ____________
Middle Ear : Right :_____________ Left : _____________
8 Flat Feet/ Lordosis/ Kyphosis(Please tick if relevant)
Summary of Current Health Condition, ....................................................................................................................................................................
9
..................................................................................................................................................................................................................................................
10 Fit to participate in physical activity Yes/ No/ with precaution ( please tick)
Name of the Doctor ........................................ Signature of Doctor....................................

(Official stamp with registration number)
....................................................................................................................................................................................................
Declaration by Parent ( Part - II)
I _____________________________________ Father/ Mother / Local Guardian of ___________________________

student of Class/ Sec. _____________________ Admission No. ______________ hereby confirm that the above said
information about my ward is correct .
Date: _______________ Signature of Parent / Guardian _________________________

HEALTH HISTORY ( Part- III)
Name of the Student _______________________ M/F __________ Class ____________
Date of Birth ________________________ Blood Group ___________________
Father's / Guardian's Name ____________________ Mother's Name ____________ _______

VACCINATIONS
Immunizaton Due Date Date
BCG
Hepatitis B
DTP
HIB
OPV
Measles
MMR
DPT + OPV + HIB
Typhoid
Hepatitis A(2 doses)
Chicken Pox
Previous History of Surgery (if any) :
BOOSTER DOSES
Typhoid (every 3 years)
TT (every 5 years )
Other Vaccines
Signature of Father / Guardian _________ Signature of Mother ___________________
Name of the Doctor ....................... Signature of Doctor ..............................

(official stamp with registration number)
.............................................................................................................................................................................
Medical Fitness Certificate ( Part- IV)
(to be signed by the Medical Officer , D.P. S. Mathura Road )
Certificate that I have examined Master/ Miss _______________________ Class / Section ________ and he/ she is
medically fit/ unfit for admission in the School/ Hostel.
Remarks , if any___________________________________________________________________
Date : ________________ Signature of Medical Officer____________________

D.P.S. Mathura Road

Delhi Public School, Mathura Road, New Delhi-110003: Health History (Part-I)

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DELHI PUBLIC SCHOOL, MATHURA ROAD, NEW DELHI-110003

Weight at time of birth.............................................. Length at time of birth ......................................

Any special medical treatment given in first 4 weeks after birth

4 PULSE: B.P. : ____

Name of the Doctor ........................................ Signature of Doctor....................................

Declaration by Parent ( Part - II)

I ___________ Father/ Mother / Local Guardian of _

Date: _ Signature of Parent / Guardian ___________

Name of the Student _________ M/F Class

Date of Birth ______ Blood Group _

Father's / Guardian's Name ______________ Mother's Name _

Signature of Father / Guardian _ Signature of Mother ___________

Name of the Doctor ....................... Signature of Doctor ..............................

Date : Signature of Medical Officer____

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