SAMPLE XYZ Charter

IMMUNIZATIONS DUE

DT______________

RUBEOLA__________________

CUMULATIVE HEALTH RECORD

SCHOOL: ___________________________________________________________________________________

NAME: __________________________________ SEX:________ DOB:_________________________________

STUDENT ADDRESS: __________________________________ CITY _____________________________ STATE ________ ZIP _________________

PHONE: ______________________________________________ LIVES WITH: __________________________________________________________

USE

P

E

N

C

I

L

Name of Parent/Guardian

Place of Business

Phone Number

If Parents Cannot be Reached

Phone Number

FATHER:

MOTHER:

PHYSICIAN:

PHONE:

HOSPITAL:

DENTIST:

PHONE:

Immunization Record

Physical Progress

Limiting Health Problems

	1^ST dose m/d/y	2^nd dose m/d/y	3^rd dose m/d/y	Booster m/d/y	Booster m/d/y	Booster m/d/y
DPT/DT
Td
POLIO
RUBEOLA Red Measles
MUMPS
RUBEOLA German
HIB
HEPATITIS B
CHICKEN POX

Source

Grade

Age

Date

Ht.

Wt.

CONDITION

Date m/y

II. 33