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Personal Information
-- Select Gender --
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-- Select Descent --
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Select School Name
Alpha Private School
Alpha School
AWLM
Gems School
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RAK Academy
RAK American Academy
RAK Modern School
St.Mary Private High School
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Physical Information
-- Select Height in cms --
-- Select Weight in kgs --
Medical Information
Family History (Parents / Grand Parents) had Cardiac Problem / Cancer
Yes
No
Not Aware
Your Vital Readings
Not Aware
Not Aware
Are you currently on medication
Yes
No
Diabetes
Bleeding Disorders
Asthma
Fracture
Seizures
Polio
Dental Screening
Normal
Review Required
Cavity
Malformation
Plaque
Gum Problems
Eye Testing
Visual Acuity
Without Glasses
With Glasses
Normal
Review Required
Normal
Review Required
Distance
Right Eye
Left Eye
Near
Right Eye
Left Eye
ENT
a. Ear
Normal
Refer to Doctor
Wax
Hearing Difficulty
Perforation
Discharge
b. Nose
Normal
Refer to Doctor
Polyp
Deviated Nasal Septum
c. Throat
Normal
Refer to Doctor
Tonsils
Congestion
Soreness
Lifestyle Information
Daily intake of fruits & vegetables
Yes
No
Milk / Curd / Eggs (Any) eaten daily
Yes
No
6-8 glasses of Water Daily
Yes
No
Meat or Beans, lentils, gram eaten 3-6 times weekly
Yes
No
Commercial foods, drinks, desserts, sweets, Icecreams (any) 3-6 times weekly
Yes
No
Outdoor activity (games & sports) for 1-2 hours, 5-6 days a week
Yes
No
Can you touch your toes
Yes
No
Are you happy in school?
Yes
No
Are you happy & comfortable at home?
Yes
No
Do you have many friends?
Yes
No
Do you have enough (8 hours) sleep & relaxation time?
Yes
No
Are you uncomfortable with anyone? (Friend, teacher, relative) etc (Opitional)
Yes
No
Ages 13-18 Years
Do you or any of your friends occasionally or frequently associate with
a) Smoke/Sheesha
Yes
No
b) Alcohol & Drugs
Yes
No
c) Rash & negligent driving
Yes
No
