UNALASKA CITY SCHOOL DISTRICT

CUMULATIVE SCHOOL HEALTH RECORD
NAME ________________________________
ADDRESS _____________________________
FATHER_______________________________
BIRTHDATE_____________________M____F____
PHONE____________________________________
MOTHER __________________________________
GRADE
WEIGHT
HEIGHT
VISION
  1 % 1 %
BOTH
RIGHT
LEFT
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
         
wo
w
wo
w
wo
w
HEARING
R
L
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
RECORD OF IMMUNIZATION AND TESTING
  DATE
DPT
        X
DT
         

Trivalent Oral Polio (Sabin)
      X  
MEASLES
      X X
MUMPS
  MMR    
RUBELLA
         
HEP-A
X X      
HEP-B
X X X    
TUBERCULIN TESTING
MONOVAC (DATE/RESAULT)
         
         
PPD (TB)
X        

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