Fro LFX0

Fro LFX0 CUMULATIVE HEALTH RECORD ANNUAL PHYSICAL INSPECTION FULL NAME SEX SCARLET FEVER( ) FIRST MIDDLE DATE OF BIRTH CHECK DISEASES HAD (,/) RHEUMATIC FEVER ( ) DIPHTHERIA ( ) SMALL PDX ( ) PERTUSSIS (WHOOPING COUGH) ( ) CHICKEN PDX ( ) MUMPS ( ) MEASELS ( ) CODE: NO DEFECTO Ogle X DEFECT CORRECTED DEFECT BEING TREATED TD En it t-c.c.I YEAR I -s-% reNE-S. un' qfr- 'II I 19 [repeated 13 times] HEIGHT Z WEIGHT COmil uret. 0.•a •••600.0 7 VISION RIGHT O 9 VISION LEFT 4 Pj 0 i es) HEARING RIGHT 60 O c HEARING LEFT CI Z TEETH THROAT tftlrheradiseleSMob SCOUOSIS •IsomPOOM OXAMITMAM O ant Q41 0 POSTURE SPEECH PARENTS/GUARDIAN NOTIFIED ( ) • EXAM or PHYSICIAN) (Yi. 9-/0-4:1„. EXAMABY DENTIST) ( )• BMIUMPATION HISTORY INA MO DAY V POMO MO DAY VA 1 IC Z . 134 I A I I- lc- A, It- io-8? it, S ICIS C:h4c 4'.4?..att;....f. m I- I- S. 2 I- t- VI? ii. e . `WS ..a kla kq lAqt.I;n i* ' ir.l'h , t“,,,(..h_ st)) .,i;:c k. -Age 4 1- 1.44 - tit c- I - PI D Ce I '" t 1 1.-1 - 90 ' S : -4, 1:44.Pilag s ,:i...9(3/5 q•k4i.- '41. n".5 . ',' ' ; ‘ • k J I: A ' '' I 0 -.IL 9.-n-cm.. . ' _ .4“- =typtiimral.s,:_kcCIV"), (*When nn mernani • CONFIDENTIAL REMARKS MMa0 00009 3501.178-008 Page 1 of I EFTA 00071439 EFTA01247937