1. No category

Ssr E
Middlo Name
E
(ch'c(Ar-Lthat
E
llorlli
ln.unncr
(lncludlng iledlcdd)?
E
tr
tr
0ru0!
Fooos
O 0her
__t__t_
tr
Amoricsn lndian
Nativo Hawaiian/Pacific l8landor
ll
Asian
tr Black E
Whlt8
0fi8r
l{o
Doo3 h0 child/adoloscsnt havs ! pEst 0r prosont medical history ol tlto following?
trl Astrma Ehsck seyetily end atach liAF/ABthn, Acttur Ptan): D lnlermlttsnt D Mild Psrsistent D Modsrats Porslslont E SoYorg Porsl8lont
tryststentcheckattclnrontme(tba]tf'/(s): Elnhalsdcorticosterl0d Eohorconfoller EQulckr8llelmod Eoml stsrold Eliono
fl
E
E
Dst6 ot Binh (Mnh/Dayl1at)
Male
trYer
Elrth hlatory /rtr o-6rrt
Allorglil
wM
Female
Attenfon Delicit HyperactivlU Dlsorder
Chmnlc or rocunent otitis msdis
El Congenihl or acquked tJoart dlsordsr
E
None E Epl pen prescrlbed
/t!t
(rt
El
Dovslopmsnial/learning
E
Dlabgtes ptbch
problem
E
orthopedic iniury/dlsablllv
n
Selzurs disordsr
E
Speoch, hearing, or visual impairmenl
E
Tuberculosis (at'nt lnloctlut ot dtseas,)
Modicauonr Ptuch huF ll ln-.ciffi ntdluaon nodtcd)
D
None
QYss (tlstbelott)
ian
Dlotary nEstrlctlons
E None
7r9
QYes 0uoenw)
Explaln all ahrarctt ltont tbota ot on addendum
Gonoral Appoarancsi
M
trn
xttn'
Hsad Clrcumtsrd|cc (rcc t2
Blood PrBssrr
Dsnhl
Neck
E
tl
M
M Abtil
Nl Abnl
fl D
tr tr
HEENT
Lungt
Cardlov88cular
D
ft
conitourlnary
Extrsmltles
tru
trtr
Skio
lisurologlcal
Bacldspine
htt
E
E
El E
E
Psychosoohl Dsvslopmont
D
Languags
Eshavloral
Doscrlbo abnormalltlsrl
w)
atrrd
E Wltln
normal llmlb
-kg
Cognttvc (c,1., pht
SCREEI{IIIGTESTS undon,
BlootlLoadLoyol
lf dolay ruspcctrd, lpoclfy bclow
(BLL)
taqulndrtry6l yaN2yn
adrottto8cetry
ddIE)
RtskA$essment
(annMos6snn-ayrs)
Pursbnoaudiometry
n
OAE
Homogloblnor
-
Hemah,ctft(ago9-12n0)
__t
__t
__t __
__t __
Eetut'
Tuborcul0lis
I __,__, __ l_!S/oL
0 Ril
phyCcal
actMtl tr
D
l-trg/dL
I
l,__,__
lElAtdsrroarq
I E'.triil.i
I
I --r
--r -*
lENormal
I E Abnormal
chestx-ray I
I
I __r__r_*
l-S/dL
Vision
PPDlVantoux
placed I
--,--r--
PPD/Mantoux/sad
| lnduraUon
| trNeg
l--r--r--
lnterforonTest l--r--r--lQNog
lnn'
AtPnqhwtennpodnfll
I
ert ciildlan w +7 w)
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EPos
ltrlOnt
I
Acutv
EPos
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lndlcatsd
nbil_t _
vrltn OtassBs-
Lcfi_l _
|
| Sfabhmus tr No E
ftrg
lCD.o oodo
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Ai0ESsMEtlT tr tveil
Full diet
Special
lnly nQul6d lot ttudsnls snlodng ktsmedltlilnlddlilluniil c,t hlgh tchool
nho han Nl WtMsly ttl\nd$ tn! NIC publE ot pdltl| tchor,l
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Educatlon E Dental trMslon
Hoath Corc Provldcr $gnatm
City
Telophono
M
Abnl
tr'tr
Abdomen
(rCrrSrrl
DEYEL0PMdlTril. {rrr
E
ht{
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State
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Dlagnor0s/Pr0bt6mr
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