Student Medical Examination

Date of examination *

Student name (surname first) * Student number Date of birth * Class / Grade * Residential address Parent / guardian phone * E-mail Blood group & genotype * Height / Weight

Medication used in the past Medication currently in use

Vaccines received (list)

Other

Scalp, skin and hair Nose and throat Mouth, teeth and gums Thyroid gland Lymph nodes Heart Lungs Abdomen Bones and joints Muscle tone Posture Nervous system Hernia Skin marks Vision / hearing General emotional status Other

Comments Restrictions

Name * Hospital / clinic * Registration (MDCN) number * Date * Telephone / e-mail *