HORMISDALLEN SCHOOLS
P.O. BOX 30223, KAMPALA
Education Has No Money Value
Email: admin@hormisdallenscools.com
www. hormisdallenschools.com
GENERAL HEALTH INFORMATION FORM
Name of student: …………………………………….…………… Class:…….. Age:….. Weight: …… Sex …
Address: ……………………………………..……………. Contact:………………………………
1. General Examination:
Sick looking Health Temp………….
Yes No Yes No Yes No Yes No
Jaundice Anaemia Dehydration Oedema
2. Medical History:
Is the child on any Treatment ……….(Yes / No) If Yes, Specify ………………………………………
Any Drug Reactions ……………………………………………………………….………(Yes / No)
3. Chronic illnesses: Yes No Yes No Yes No
Asthma Sickle cell Diabetes
Kidney Disease Mental illness Hyper tension
Heart Disease Cancer Others ………………
4. Respiratory system
Respiratory rate …………………………………. SPO2 ………………………………………
Yes No Yes No
Difficulty in breathing Chest pain
Cough Flue
Allergies
5. Skin
Yes No Yes No Yes No
Eczema Scabies Ring worm
Chicken pox Tinea capitis Skin Allergies
Any other specify …………………………………
6. OPTHEMILOGIST’S (Observations & Recommendation)
L/E………………………………………….. R/E………………………………………………………
………………………………………………………………………………………………………………
7. ENT (Observations & Recommendation)………………………………………………………………. ….
8. DENTIST’S REPORT (Observations & Recommendation)
…………………………………………………………………………………………………..……………
………………………………………………………………………………………………….…………….
9. LABORATORY INVESTIGATIONS
- Urinalysis - B/S/Mrdt - Widal - Covid-19
10. Doctor’s Recommendation
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Doctor ………………………………… Sign:……………………………. Date & Stamp
N.B: Lab Results should be attached to this form
