Student Medical Report

Student Medical Report

Student Information

Student Name:

[Your Name]

Student ID:

123456

Grade/Class:

5th Grade

Contact Information:

[Your Email]

Medical History

  1. Allergies:

    • Food Allergies: Peanut, Tree nuts

    • Environmental Allergies: Pollen, Dust mites

    • Medication Allergies: Amoxicillin

  2. Chronic Conditions:

    • Asthma: Diagnosed at age 5; currently managed with an albuterol inhaler as needed.

    • Eczema: Occasional flare-ups during winter months; managed with topical creams.

  3. Medications:

    • Albuterol Inhaler: 90 mcg, as needed (usually 1-2 times per week)

    • Hydrocortisone Cream: Apply twice daily during eczema flare-ups

  4. Past Surgeries/Significant Illnesses:

    • Tonsillectomy: Performed on 06/20/2065

    • Bronchitis: Experienced severe bronchitis in 2063; no recent episodes since treatment.

Current Health Assessment

  1. Date of Examination: [09/25/2060]

  2. Conducted by: Dr. Sarah Smith, Pediatrician, ABC Pediatric Clinic

  3. Reason for Visit:

    • Annual wellness check-up and asthma management review.

  4. Findings:

    • Vital Signs:

      • Height: 4’10” (50th percentile)

      • Weight: 85 lbs (55th percentile)

      • Blood Pressure: 100/60 mmHg (normal range)

    • Physical Examination:

      • Lungs clear upon auscultation; no wheezing detected.

      • Skin examination shows eczema well-controlled with current treatment.

    • Additional Tests:

      • Spirometry test shows 95% lung function, indicating good asthma control.

Recommendations

  1. Treatment Plan:

    • Continue current asthma management plan; provide a rescue inhaler for use during physical activities.

    • Continue using hydrocortisone cream for eczema, especially during winter months.

  2. Follow-Up Care:

    • Schedule a follow-up appointment in six months for asthma management.

    • Consider referral to an allergist for further evaluation of environmental allergies if symptoms persist.

  3. Activity Restrictions:

    • No restrictions on physical activity; however, the student should have access to their inhaler during physical education classes and sports activities.

    • Avoid exposure to known allergens (peanuts, pollen) as much as possible.

Emergency Contacts

  1. Name: Jane Doe

    • Relationship to Student: [Mother]

    • Phone Number: [(123) 456-7890]

  2. Alternate Emergency Contact:

    • Name: Emily Johnson

    • Relationship to Student: Aunt

    • Phone Number: [(321) 654-0987]

Acknowledgment

I, the undersigned, acknowledge that the information provided in this medical report is accurate and complete to the best of my knowledge. I understand that this information will be used to ensure the health and safety of my child while at school.

Signature

[Parent/Guardian's Name]

[Date]

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