1. Medical Facilities Evaluation Proforma
Name of School
Session & Classes
Doctor Date of Visiting Hours
Name appointment
Nurse Date of Visiting Hours
Name appointment
Medical Room equipment-
Item No. Item No. Item No. Item No.
Table Washbasin Wheel Chair Water bottle
Chair First aid Box Stretcher Disposable
Glasses/spoons
Bed Refrigerator BP Hand Towel
Instrument
Weighing Examination Fire Match Box
Scale Table Extinguisher
Height Thermometer Umbrella Thread/Needle
Scale
Medical Record
Medical Register Student Report
cards Diary card
Medical Check up done for classes-
First Round Second Round
No. of Students referred to specialist-
First Aid Diet Epilepsy
Eye Dengue Orthopedic
Ear Polio Cardiac
Dental Diabetic Children with
special need
Physician Asthma Other
Tie up with nearest Hospital
1
2
Follow up of students referred to specialist-
Any other info