Health Form 602 - Student Physical Examination - Matanuska-Susitna Borough School District From

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HEALTH FORM 602 (7/27/07)
MATANUSKA-SUSITNA BOROUGH SCHOOL DISTRICT
STUDENT PHYSICAL EXAMINATION
Student Name __________________________________ Date of Birth______________ School_______________________
Parent’s Name____________________________________ Phone Number________________________________________
This physical examination is required to be performed by a physician (M.D., or D.O.), advanced nurse practitioner
(A.N.P.), physician’s assistant (P.A.) or a chiropractor (D.C. , within scope of chiropractic practice).
Note: This form is not to be used for athletic physical examinations.
PHYSICAL EXAMINATION
Height____________ Weight____________ B/P___________ Vision: Both__________ Right__________ Left __________
Cover______ Color Acuity_________ Hearing: Right________ Left_______ Audiometer used_______ /or Other_________
Exam Finding:
○ = No abnormality √ = Abnormality- specify under comments section
Eyes______________________________________
Ears___________________________________
Nose/Throat________________________________
Mouth_________________________________
Lymph Nodes_______________________________
Teeth__________________________________
Heart______________________________________
Lungs__________________________________
Abdomen__________________________________
Genitals________________________________
Orthopedic_________________________________
Nervous System_________________________
Skin______________________________________
Endocrine______________________________
Nutrition__________________________________
Other__________________________________
Comments/Follow-up Needed: ___________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
IMMUNIZATION RECORD or attach copy
Note: Month, day and year must be present to be considered valid
DTP/DTaP
Td/Tdap
Polio
MMR
Hep A
Hep B
Varicella
Hib
PPD
Other:
__________________
____________________________________________________
Date
Signature of Physician M.D. or D.O.,/A.N.P.,/P.A.,/D.C.
__________________
____________________________________________________
Phone Number
Printed Name of Physician M.D. or D.O.,/A.N.P.,/P.A.,/D.C.

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