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. 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...
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 Benadryl yes no Antacids yes no Neosporin 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 malignancy/tumor bowel problems frequent sore throats hay fever bed wetting
Health History. If you answer yes to any of these questions, the person giving you the vaccine may need more information from you before you get the vaccine: CO V I D - 19 VA CCI N E SCREEN I N G A N D A G REEM EN T Yes No Unknown Question Yes No Are you the correct age to receive the COVID-19 vaccine? • Pfizer-BioNTech vaccine: You must be 16 years or older. Yes No Unknown Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine? Yes No Unknown Immediate allergic reaction (within 4 hours) of any severity to a previous COVID- 19 vaccine dose or known (diagnosed) allergy to a component of the vaccine or any of its ingredients (including polyethylene glycol [PEG] or polysorbate)? Yes No Unknown Immediate allergic reaction to any other vaccine or injectable therapy (e.g., shots in the muscle (intramuscular), in the vein (intravenous), or into the fatty tissue (subcutaneous)? Does not include allergy shots. Yes No Unknown Are you feeling sick today? Yes No Unknown Received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the past 90 days? Yes No Unknown Exposed to another person with known COVID-19 disease? Yes No Not applicable Have you ever received a dose of COVID-19 vaccine? If yes, list vaccine product and date received: Yes No Not applicable Did you have a delayed allergic reaction at the injection site (e.g., redness, itching) after a first dose of COVID-19 vaccine? Yes No Unknown Have you received any other vaccines (that were not COVID-19 vaccine) within the past 14 days? Yes No Not applicable Are you pregnant? DO NOT WRITE BELOW THIS LINE Vaccine information COVID-19 Vaccine Presentation1 EUA Fact Sheet Date Route2 Manufacturer3 Lot Number Admin Site4 Person Admin5 COVID-19 (Pfizer) IM PFR Left deltoid/Right deltoid
