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Medical Report Sample For School Example [Edit & Download]

Last Updated: October 14, 2024

Medical Report Sample For School Example [Edit & Download]

Medical Report for School

Student Information

  • Name: Emily Carter
  • Age: 12
  • Grade: 7
  • Date of Birth: August 8, 2011
  • Student ID: 12345

Report Details

  • Date of Report: October 14, 2023
  • Physician’s Name: Dr. Lisa Morgan
  • Healthcare Facility: City Pediatric Clinic

Medical History

  • Current Conditions: Asthma, Seasonal Allergies
  • Past Medical History: No major illnesses or surgeries
  • Allergies: Pollen, Dust

Examination Findings

  • General Health: Good overall health with controlled asthma.
  • Recent Symptoms: Occasional shortness of breath during physical activity, especially in outdoor environments.

Diagnosis

  • Primary Diagnosis: Asthma
  • Secondary Diagnosis: Seasonal Allergies

Treatment and Recommendations

  • Medications:
    • Albuterol Inhaler: As needed before physical activity or when symptoms occur.
    • Antihistamine (Cetirizine) 5 mg daily during allergy season.
  • School Accommodations:
    • Access to inhaler during school hours.
    • Limit outdoor physical activities on high pollen days.
  • Lifestyle Recommendations: Encourage indoor activities during peak allergy seasons and avoid exposure to dust.

Follow-Up

  • Next Appointment: Scheduled for January 14, 2024
  • Monitoring: Teachers and school nurse should monitor for asthma symptoms and administer inhaler as needed.
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