Ohio Department Of Health (School And Adolescent Health) Physical Examination
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2Ohio Department of Health • School and Adolescent Health
Physical Examination
Student’s name
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Male
Female
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B
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P
Screening Tests
H
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P
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Vision
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d
/
/
/
/
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Distance Acuity
R
L
Pure Tone
No abnormality noted
Muscle Balance
Pass
Fail
Right ear
Pass
Fail
Screening not done
Stereopsis
Pass
Fail
Left ear
Pass
Fail
Referral made
Color
Pass
Fail
Child wears hearing aid?
Yes
No
Comments
Child wears glasses?
Yes
No
Child under the care
of a hearing specialist
Yes
No
Tested with glasses?
Yes
No
Referral made?
Yes
No
Referral made?
Yes
No
S
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L
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Speech assessment completed
Yes
No
Date _________________ Type
C
V
Results_______________ µg/dL
Child has no discernible speech problem
Yes
No
Date _________________ Type
C
V
Results_______________ µg/dL
Speech evaluation recommended
Yes
No
Tuberculin Test
Child has possible problem with ___________________________
Date ____________________ Type ______________
Results_____________________
Health History
(Serious or chronic illnesses/injuries/surgeries)
/
/
Physical Examination
Date of most recent examination
Essentially normal
Abnormalities as follows
Is this child able to participate fully in:
Classroom and academic activities
Yes
No
Physical education classes
Yes
No
Competition athletics
Yes
No
Contact and collision sports
Yes
No
If limitations are advised, please specify
Does this child have any physical, developmental or behavioral issues that may affect his/her educational process?
H
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)
Address
Date
/
/
City
State
ZIP
HEA 4242 8/06
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