Name Of The Student Emergency Phone Number(to reach parents) Physician To Be Called Emergency(name) Address Phone Guardian / Relative To Be Called In Emergency(Name) Address Phone Has your child ever had the following illness? , If so, When?? Name Yes / No Date Chickenpox YesNo Measles YesNo Diphtheria YesNo Malaria YesNo Heard Dieases YesNo Blood Group YesNo Epilepsy YesNo Tuberculosis YesNo Ear Condition YesNo Asthma YesNo Allergies YesNo Others Serious Injury YesNo Name Operation YesNo Name Has your child ever had the following protective measures? , If so, When?? BCG Vaccination YesNo Polio YesNo Tetanus YesNo Hepatitis A & B YesNo Date of last physical check-up
