Student Medical Report

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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.

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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.

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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.

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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]

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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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