MEDICAL INSPECTION OF SCHOOLS
School
Teacher
Room
Name
Address
Date
Sent to Inspector for
To bo filled by Teacher and sent with Pupil to Inspector
Diagnosis
Code No.
Disposal - Referred to Physician
Matron
Returned to room
Zero
Given R I
Excused for day only
Note to Parents
S.
P.
R.
Excluded date
To return
Readmitted
Dates of re-inspection
Result Cured
Improved
Not improved
Advised treatment
Teeth Good
Poor
Fair
Tonsils Yes
Result
No
Vision Good
Hearing-Good
Defective
Adenoids-Yes
Defective
No
Result
VaccinationYes
Result Good
No
Vaccinated, date
No scar
Total exams.
M.D.
Record inspection by underlining
Inspector
-A
Library Bureau S1902
HEALTH DEPARTMENT,
Springfield, Mass.