Health History. To provide the Secretary of the BWPGCA with a fully completed Health History of the pup at twenty-four (24) months of age on a form approved and provided by the BWPGCA;
Health History. I certify that I have accurately provided my health history information below. I have the following health problems, drug allergies and/or reactions that Xavier needs to be aware of in the event of an emergency [write “none” if not applicable]:
Health History. To provide the CFNA Breeding Committee with a fully completed Health History of the Puppy at twenty-four (24) months of age or completes the IHDT, on a form approved and provided by the CFNA as well as periodic on-line health surveys.
Health History. Yes No Resolv # Is your child having any of the problems listed below? Birth History: h h h 3 Eczema or Frequent Skin Rashes h h h 12 Dental Problems: Date of Last Exam / / x x x Xxxxx (please describe):
Health History. A review of hospitalizations, significant illnesses, and other significant medical events, and the reasons for them;
Health History. CHILDREN AND ADOLESCENTS
Health History. I understand that my child must have a Child’s Preadmission Health History form on file at the Center, as required by the State licensing agency (“Physician’s Report” if not enrolled in public or private elementary school; “Parent’s Report” if enrolled in public or private elementary school). I agree to provide all required Child’s Preadmission Health History documentation to the Site Supervisor prior to starting in the program.
Health History. Is your child having any of the problems listed below? 1 Allergies or Reactions (for example, food, medication or other) 2 Hay Fever, Asthma, or Wheezing 3 Eczema or Frequent Skin Rashes 4 Convulsions/Seizures 5 Heart Trouble 6 Diabetes 7 Frequent Colds, Sore Throats, Earaches (4 or more per year) 8 Trouble with Passing Urine or Bowel Movements 9 Shortness of Breath 10 Speech Problems 11 Menstrual Problems 12 Dental Problems: Date of Last Exam Other (please describe): Birth History: h Are there any current or past diagnosis(es) If yes, please describe: Yes No Does your child take any medication(s) regularly? Reason for Medication If yes, list medications: Was the health history reviewed by a health professional? Parent/Guardian Signature Date Examiner’s Yes No Resoled PERSONAL Reading: Type: Neg.: h Pos.: h mm NOTE: Blood lead level required for all children enrolled in Medicaid must be tested at one and two years of age, or once between three and six years of age if not previously tested. All children under age six living in high-risk areas should be tested at the same intervals as listed above. Level ug/dl BLOOD LEAD LEVEL Date: / / h h Microscopic Albumin TUBERCULIN Date: / / h h Sugar URINALYSIS Date: / / h h BLOOD PRESSURE h Other: ] HEMOGLOBIN / HEMATOCRIT h h Audiometer HEARING Date: / / h h Other Other: h Weight Muscle Imbalance Height HEIGHT & WEIGHT Other: h h Visual Acuity VISION Date: / / Test results: Was child tested for: Test results: Was child tested for: Tests and Measurements
Health History. Date of last tetanus: Are immunizations current? yes no I permit my child to be given the following if needed: Ibuprofen yes no Acetaminophen yes no Antacids yes no Neosporin yes no Benadryl yes no Check the following which apply: diabetes kidney trouble ear aches frequent colds seizure constipation fainting asthma sleep walking heart trouble bronchitis athlete’s foot upset stomach frequent sore throats hay fever bed wetting malignancy/tumor bowel problems
Health History. Yes No Yes No Yes No Head or Spinal Injuries Syphilis Kidney Disease Seizures, fits, convulsions, Gonorrhea Muscular Disease or fainting _ Diabetes Suffering from any other disease Extensive confinement by illness Gastrointestinal Ulcer Permanent defect from illness, disease or injury Cardiovascular disease Nervous stomach Psychiatric disorder Tuberculosis Rheumatic Fever Any other nervous disorder Asthma If answer to any of the above is yes, explain: ____________________________________________________________________________ PHYSICAL EXAMINATION General Appearance and Development: Good: Fair: Poor: _________________ Vision: For distance: Right 20/ Left 20/ Both 20/ W/O corrective lenses With corrective lenses if worn. Evidence of disease or injury: Right Left:__________________ Color Test: Horizontal field of vision: Right Left _____ Hearing: Right Ear Left Ear Disease or injury__________________ Audiometric Test (complete only if audiometer is used to test hearing) decibel loss at 500 Hz __________ at 1,000 Hz at 2,000 Hz __________________ Throat Thorax: Heart Blood pressure: Systolic Diastolic ____________________ Pulse: Before exercise Immediately after exercise Lungs Abdomen: Scars Abnormal masses Tenderness Hernia: Yes No If so, where? Is truss worn? _______________ Gastrointestinal: Ulceration: Yes No 40)Rectal exam (Age Occult Blood Genito-Urinary: Reflexes: Xxxxxxx Pupillary Light X X ______________ Accommodation Right Left ___________________ Knee Jerks: Right: Normal Increased Absent _____________________ Left: Normal Increased Absent Remarks: Extremities: Upper Lower Spine Laboratory and other Special Findings: Urine: Spec. Gr. Alb. Sugar General Comments/Recommendation: ________________________________________________________ Date of examination Address of Medical Examiner Name of Medical Examiner Signature of examiner ADDENDUM # 4 CITY OF XXXXXX OUR MISSION To enhance the safety and well being of our community by providing quality services in a friendly and cost-effective manner OUR PURPOSE Public Service OUR VALUES Support each other in performance of job functions Encourage honesty and behavior that is consistent with our mission Maintain an open government that is a good xxxxxxx of public resources Recognize and promote competence, excellence and open communication Support decision making that is deliberate, conscientious, and based on fact CITY OF XXXXXX EMPLOYEE PERFORMANCE APPRAISAL Purpose of Evaluation System: The purpose of thi...
