Epstein Secrets

essure (I) Normal=N; Abnormal=A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3. Head/Scalp 4. Eyes 5. Visual Acuity (R & L) R Aro& °row 6. Ears 7. Auditory Acuity (11 Et L) 8. Nose / Throat 1 9. Mouth. Teeth and Gums 10. Chest / Lungs 11. Heart 12. Abdomen V 1

IST YOLR DOW'S ILLNESSES. A.LERGiEs OR OTHER PHYSICAL LMITATIONS YOUR CHILDREN IN OTHER CHOOLS: :Ill NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE OATH DATE tl 4IN — STUDENT NO. (OPTIONAL) GRADE 1531 NAME OF CHILD SCNOOI ATTENOING STUDENT NO. (OPTIONAL) GRADE BRIM DAVE 1641 NA

ure ././r / 4 Normal-N; Abnormal-A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/NoSe 3. Head/Scab 4 Eyes 5 Visual Acuity (R & L) 6. Ears 7. Auditory Acuity (R & L) a. Nose / Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs 11. Heart 12. Abdomen 13.teirr-aal-Anirem- 14

SPITAL PROT:ROME 1501 LIST YOUR CHILD'S ILLNESSES, ALLERGIES OR OTHER PHYSICAL LIMITATIONS: aff 16I/ NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE MATH OATE MI NAME OF CHILD SCHOOL ATTENDING STUDENT NO, (OPTIONAL) GRADE BIRTH DATE (53) NAME OF CHILD SCHOOL ArtFt.01M1Cr STUDENT N

e (✓) Normal=N; Abnormal=A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3. Head/Scalp 4. Eyes • . 5. Mural Acuity (R & L) . 6. Ears Ii. 7. Ati0ttory Acuity1R & L) — 8. Nose / Throat 9. Mouth, Teeth and Gums 10. Chest / Lungs 1 i. Heart - 12. Abdomen 13. Geni

S, ALLERGIES OR OTHER PHYSICAL LIMITATIONS: A) 0 lie 0007,110- cg, p'Airiel eiTeci , 1511 NAME OF CHILD Aiorc • SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE RIM DATE 1521 NAME Of CHILD SCHOOL ATTENDING STUDENT NO, (OPTIONAL) GRACIE BIRTH DATE (531 NAVE OF CHILD SCHOOL ATTENDING STUDENT NO

dings, by number 1. Appearance C < r. 2. Skin/Nose ../ 3. Head/Scalp / 4. Eyes 5. Visual Acuity IR & Ll . / 6. Ears / 7. Auditory Acuity (R & L) / 8. Nose / Throat / 9. Mouth. Teeth and Gums /,.." 10. Chest / Lungs / 11. Heart / 12. Abdomen / 4". 13. Genitals and Anus / 14. Musc

(4, GUn IVG ADDRESS .C./.1 he mar MAW( a, , ',We 41;ar orES Vrilt, 4• Ml s., 4. cn, sr *Tr t, car rrAW isi metiers SOCIAL SECURITY NO. (OPTIONAL) 161 HOME >HONE N0. il) I remAte 3 SEX F MALE (8) . e I RACE AMERICAN INNAN OP ALASKAN NATIvE. B ' NON-HISPANIC D A ttl iCti:IC I