DS9 Document EFTA01248868

1 *eel_ WARTMEC OP ' HEAL STUDENT HEALTH EXAMINATIONS Date ',/ (778 Students Full Narne Phcne APO Race Sex Address Sktbdaa Name di Parent a Guardian School A. HEALTH EXAMINATION HMO —9-2 ".1 / Weght en 5 -/Zer 8100d Pressure In NonnaleN; Abnormal-A Nt..), COMMENT: Abnormal Findings, by number 1. MOrlerance / 2. Skin/Nose 3. Head/Scat 4. Eyes ' . 5. Visual Aarily (R 11 L) ‹. 0 Ears 5 ° 7. Auditory Acuity (R & LI s.,, k. ''' 8. Ncee 1 Throat i 1 . • ''•••••1 ei 1/4(/ 9. lAcuth. Teeth and Gunn VY 10. Chest / Lungs 11. Heart 12. Altdcentm 13. Genitals and Anus • 14. IlkscubSkeletai 15, Neurological 18. Alertness 17. Emotional / Mental/ Behreact Prob.) 1a.moneccoehysicao other ISPecify) 19. Activity Restrict% Mealy) 20. Abuse. substance/ cerieal / emotional 21. Nutrition 22. Other I B. HEALTH HISTORY Serious Messes Injuries: explain) Al bra_ (attach narrative il &Mimi space needed) C. LABORATORY (as Indicated) Reeloglotan/Hemalocdt Stool (0 & P) da l I Tuberculin test, Lead Sickle Cell NAME: TITLE: ADDRESS: (Please Print) . 74 7$ • Authorized Signature bate • • (steakNtavber: 5744430.3040-2) CONFIDENTIAL 3501.225-002 Page 1 of 1 EFTA_00075147 EFTA01248868