Medical Facilities Evaluation Proforma

Name of School

Session & Classes

Doctor Name

Date of appointment

Visiting Hours

Nurse Name

Date ofappointment

Visiting Hours

Medical Room equipment-Item No. Item No. Item No. Item No.Table Washbasin Wheel Chair Water bottleChair First aid Box Stretcher Disposable

Glasses/spoonsBed Refrigerator BP

InstrumentHand Towel

WeighingScale

Examination Table

Fire Extinguisher

Match Box

Height Scale

Thermometer Umbrella Thread/Needle

Medical Record Medical cards

Register Student Diary

Report card

Medical Check up done for classes-First Round Second Round

No. of Students referred to specialist-First Aid Diet EpilepsyEye Dengue OrthopedicEar Polio CardiacDental Diabetic Children with

special needPhysician Asthma Other

Tie up with nearest Hospital12

Follow up of students referred to specialist-

Any other info