PERSONAL HEALTH CHART

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AGE CLASS__.___ADDRESS
HISTORY (Give dates and after-effects)
1. Measles 7. Tuberculosis
2. Diphtheria. 8. Whooping Cough.
3. Scarlet Fever 9. Typhoid
4. Mumps 10. Rheumatism
5. Pneumonia 11. Influenza
6. Infantile Paralysis
Operations
MEDICAL EXAMINATION
Normal (./)
Part Defect OO) Nature of Defect | Treatment Suggested
Eyes
Ears
Nose
Throat
Teeth
| Thyroid
Heart
| Lungs
Abdomen
Posture
Skin
} Peet
Hernia
Nutrition Ht. Wet. (Circle) Normal Overweight Underweight
OBSERVATION EXAMINATION BY TEACHER OR NURSE
Teeth (Dental blank observed) ______- _—s-— Hit. Wt.
Vision: Without Glasses Ru Ls Posture
With (Grasses Ry eet
Hearing (Audiometer) Bowels
Frequent Colds—Sore Throats___.___-__..... Headaches
Skin (Clean—Erupted) Mental Health
Glandular Disturbances

 

 

 

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