H Student's Ful Name Address Name of Parent cc Guardon STATE OF FLORIDA DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES STUDENT HEALTH EXAMINATIONS Da'e i/i /c/ct Phone Race Sex 1-- B:Mxtue A. HEALTH EXAMINATION Height School Blood Pressuren (/) NornsaluN; Abnormal-A N A COMMENT: Abnormal Findings, by number I.Wes/wee 2. Skin/Nose 3. Head/Scalp 4. Ewa 6. Visual Acuity & L) 6. Eas 7. Auditory Acuity Ift 8 L) 8 Nose / Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs 11. Heart 12. Abdomen 13. Genitals 14. Musculo-Skeleta/ IS. Neurological 16. (Vainest 17. Emotional / Mental/ Behavior Preb.) IS. Handicap. physical/ other (Specify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ PRY:Real / emotional 21. Nutrition 22. Other B. HEALTH HISTORY (se6ous illnesses Injuries: Cudain) (attach narrative it additional space needed) O. LABORATORY (as indicated) Hemoglobln/Hematccrit Stool (O & P) Ttberculin test: Lead Sickle Cell NAME. TITLE: ADDRESS: (Please Print) ramts v imGcNtrARP eENTSR 1216 Ro issI Palm Beach Blvd. 1 Royal L 33411 fn'o date res Autho zed Signature MRS-II Form 3040, Me/ 91 (0bsotetes previous editions) (Stock ember: 5744-000.3040-2) CONFIDENTIAL irlf 3501.178-015 Page 1 of 1 EFTA_00071446 EFTA01247939