Student Medical Record Form
Student Name:
Class:
Select
NURSERY
JRKG
SRKG
I
II
III
IV
V
VI
VII
VIII
IX
X
XI-COM
XI-SCI
XII-COM
XII-SCI
Division:
Roll No:
GRN:
Date of Birth:
Gender:
Select
Male
Female
Other
Blood Group:
Select
A+
A-
B+
B-
AB+
AB-
O+
O-
Allergies:
None
Food
Dust
Pollen
Medicine
Vaccination Details:
BCG
DPT
Polio
MMR
Hepatitis B
Typhoid
Tetanus (TT)
COVID-19
Student’s Height (cm):
Student’s Weight (kg):
Any recent illness or surgery:
Is the child suffering from any of the following?
Asthma
Diabetes
Epilepsy
Heart Disease
None
Declaration:
I hereby declare that the information provided above is true to the best of my knowledge.
Name of Parent/Guardian filling this form:
Submit