SI14-33-H1R3 HEALTH INFORMATION 06/12/00 12.32.34 STUDENT ID 5272852 it STU ID LEGAL NAME: LAST CURRENT SCHOOL 5101 GRADE 04 59398381.0rTUS A SEX F ETHNIC FIRST MIDDLE HR SE DATE ENTERED 08 BIRTHDATE 06 MEDICAL REASON EFFECTIVE DATE / / IMMUNIZATION: 1 EFFECTIVE DATE / / TB TEST RESULT S VACCINE STATUS: DTP: DT: TD: POLIO: MMR: MEASLES: MUMPS: RUBELLA: HIB: HEPATITIS B: EXPIRATION DATE H APP / 30 / 99 / 07 / 90 / / HEALTH EXAMINATION Y 07 24 90 11 12 90 02 06 91 07 17 91 08 12 94 MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY TD BOOSTER: MM DD YY 07 24 90 09 17 91 11 12 91 08 12 94 09 17 91 08 12 94 MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY SCREENING FOR HEARING PROBLEMS: Y I MEDICAL ALERT _ PH: ( SCREENING FOR VISION PROBLEMS Y CONTACT CONFIDENTIAL MM08-S NUEVA-000020 3501.160-036 Page I of I EFTA_00069504 EFTA01247278