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Medical Record
FIRST NAME (Nombre): _____________________________________ LAST NAME (Apellido): ___________________________________
GENDER (Género): M □ F □
DATE OF BIRTH (Fecha de nacimiento): Day_______ Month________________ Year _______
PLACE OF BIRTH (Lugar de nacimiento): ______________________________________________________________________________
FATHER’S NAME (Nombre del padre): ________________________________________________________________________________
BUSINESS PHONE (Teléfono oficina): _______________________ HOME PHONE (Teléfono casa): ____________________________
MOTHER’S NAME (Nombre de la madre): _____________________________________________________________________________
BUSINESS PHONE (Teléfono oficina): _______________________ HOME PHONE (Teléfono casa): _____________________________
DOCTOR TO CONTACT IN CASE OF EMERGENCY (Nombre
PERSON TO CONTACT IN CASE OF EMERGENCY (Nombre
del médico a llamar en caso de emergencia) de persona a llamar en caso de emergencia) _______________________________________________________ _______________________________________________________ PHONE (Teléfono): ____________________________________
PHONE (Teléfono): ____________________________________
THE FOLLOWING SHOULD BE FILLED IN BY THE PEDIATRICIAN OR FAMILY DOCTOR (Las siguientes informaciones deben ser
llenadas por el pediatra o medico de la familia). A. NUTRITION (Nutrición) ____________________________
HEIGHT (Tamaño) ___________________________________
WEIGHT (Peso) _______________________________________
BLOOD PRESSURE (Presión arterial) ___________________
EYES (Ojos): LEFT (Izquierdo) ___________________________
RIGHT (Derecho) ___________________________________
EARS (Oídos): LEFT (Izquierdo) _________________________
RIGHT (Derecho) ___________________________________
NOSE (Nariz): ADENOIDS (Adenoides) __________________
NASAL OBSTRUCTION (Obstrucción nasal) ___________
THROAT (Garganta): Tonsillitis (amigdalitis) _________________ Frequent Colds (Resfriados frecuentes) ______________
Laryngitis (Larengitis) __________________________________
SKIN (Piel): _________________________________________
GLANDS: Hypertrophy of Lymphatic ganglion ___________
LUNGS: ______________________
HEART: Apex _________________
ABDOMEN: Palpable Mass _____________________________
Hernia _____________________________________________ NERVIOUS SYSTEM: ____________________________________
Reflex _____________________________________________ ORTHOPEDIC: __________________________________________________________________________________________________
IS PATIENT ON TREATMENT FOR ASTHMA OR CONVULTIONS? SPECIFY TYPE OF MEDICATION AND DOSAGE ___________
________________________________________________________________________________________________________________ ANY RESTRICTION TO PARTICIPATE IN ANY SPORT ACTIVITY? _______________________________________________________
REASON ____________________________________________________________________________________________________
SPECIFY ANY OTHER PHYSICAL CONDITION OR ILLNESS THAT MAY AFFECT THE CHILD AND SHOULD BE NOTIFIED TO THE
SCHOOL (Especifique otra condición médica o enfermedad que pueda afectar al niño(a) y que el colegio deba estar
enterado) _____________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ALLERGIES (Alergias) ___________________________________________________________________________________________________
CBC: Hect. _______________________________ Hb. ___________________________ Urine (Orina) ________________________________
BLOOD TYPE (Tipo de sangre) _________________________________
B. INMUNIZATIONS DATES (Fechas inmunizaciones):
Chicken Pox (Varicela) ____________________ BCG _____________________ MMR ____________________________ C. PAST ILLNESS (Enfermedades anteriores):
Chicken Pox (Varicela) ________ Tonsillitis (Amigdalitis) _______ Rheumatic Fever (Fiebre reumática) _______ Measles (Sarampión) __________ Meningitis __________ Otitis __________ Geman Measles _________________ Epilepsy __________ TB _________ Mumps (Papera) __________ Hepatitis ____________ Diabetes ____________ Polio ____________ Pneumonia __________ Surgeries (Operaciones) __________________ Diphteria ___________ Bronchitis __________ Other (Otros) _____________________________________________________________________
III. MEDICATION TO BE GIVEN (Medicamentos que el alumno debe tomar):
If any of the following symptoms occur, you may give the child (Si el alumno padece de algunos de los síntomas descritos 1. Headeache or fever (Dolor de cabeza o fiebre): Winasorb tablet Yes _______ 3. Allergies (Alergias): Loratadine/Atarax/Claritine D Syrup Yes ______ 4. In case of Asthma (en caso de asma): Salbutamol 5. Nasal Congestion (Congestión nasal): Ambroxol DATE OF PHYSICAL EXAM (Fecha de examen físico) ______________________________________________________________________
DOCTOR’S PHONE (Teléfono del doctor) ________________________________________________________________________________
DOCTOR’S NAME (Nombre del doctor) __________________________________________________________________________________
DOCTOR’S SIGNATURE (Firma del doctor) ________________________________________________________________________________

Source: http://assd.edu.do/assd_db/files/FORMmedicalrecord.pdf

C:\documents and settings\disp\my documents\media releases\media release - undercover drug operation nets 163 indictments - 4-2

Office of the SheriffAnderson County, Tennessee FOR IMMEDIATE RELEASE Undercover Drug Operation Nets 163 Indictments One hundred sixty-three indictments for eighty-eight persons on drug related charges havebeen returned by an Anderson County Grand Jury after investigations by the AndersonCounty Sheriff’s Department in cooperation with the Tennessee Bureau of Investigation,the Oak Ridge, La

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