(FORM 68)
RECORD.
PHYSICAL
Birthplace
Sex
Age
Mother
Nationality of Father
History of Measles
Number of Children in Family-
Scarlet Fever.
Pneumonia
Pertussis.
Diphtheria
Vaccinated?
School
191
Date of Examination
O Placed in square means absence of defects. X Denotes defects.
4
5
6
2
7
JGrade
2 Years in School
3 Revaccination
4 Diseases during year
5 Date of Physical exam.
6 Height
7 Weight
Nutrition
8
9 Anemia
10 Enlarged glands
I Goitre
12 Nervous diseases
13 Cardiac disease
14 Pulmonary disease
15 Skin disease
Defect orthopedic
Rachitic type
17
18 Defect of vision
19 Other diseases of the eye
20 Defect of hearing
21
Discharging ear
22 Defect of nasal breathing
23 Defect of palate
24 Defect of teeth
25 Hypertrophied tonsils
26 Adenoids
27 Mentality
28 Conduct
29 Effort
30 Proficiency
31 Was treat ment advised?
DEPARTMENT
OF
HEALTH-
CITY OF HAVERHILL
MASS.
NAME
ADDRESS
