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Student Wellness Screening Record

Periodic school screening log: growth, vision/hearing, vaccination and referral — by the health officer.

11 questionsThis template's questions aren't translated into your language yet — the form will be created in Persian.
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This template includes the welcome and thank-you screens, the questions and the jump logic below. "Use this template" creates a draft form you can edit.

  1. 1.

    نام دانش‌آموز

    Short answer

  2. 2.

    کلاس / پایه

    Short answer

  3. 3.

    تاریخ پایش

    Date (Jalali)

  4. 4.

    قد (سانتی‌متر)

    Number

  5. 5.

    وزن (کیلوگرم)

    Number

  6. 6.

    نتیجه هر غربالگری:

    Matrix

  7. 7.

    واکسیناسیون طبق سن کامل است؟

    Yes / No

  8. 8.

    توضیح موارد نیازمند پیگیری/ارجاع و اطلاع به خانواده

    Long answer

Student Wellness Screening Record — Porsand