School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana Page 3
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4KEY: WNL = Within Normal Limits
UTD = Up to Date
UTO = Unable to Obtain
STATE OF LOUISIANA
IP= In Progress
COMPREHENSIVE PHYSICAL EXAMINATION REPORT
PART 3: To be completed by a licensed physician/licensed nurse practitioner in collaboration with a licensed
physician or a licensed physician’s assistant under the supervision of a licensed physician.
Name: ______________________________________
Ht. __________ Wt. __________ BMI __________ Age __________
DOB: ______________________________________
BP __________ T __________ P __________ R __________
Current Meds:
Allergies:
Past Medical History
Family History (cont.)
Environmental Assessment
Major illness __________________________
Diabetes______________________________
Water supply: City Well None
Hospitalizations/Surgeries _______________
Cancer_______________________________
Sewer system: City Septic None
Heart Disease__________________________
Smokers in the home? _________
Immunizations (incl. Varicella):
UTD
IP
Sickle Cell____________________________
Pets in home: List:______________
Note: Attach proof if school entrance form.
T.B._________________________________
Family History
Other:________________________________
Allergy or Asthma______________________
(Note family member’s relation to patient.)
Nutritional Assessment
Dental Assessment
Reproductive
Menarche age______ LMP_______
Special Diet _____________________
Any Dental Disease
Yes
No
Vitamins/Supplements _____________
Dental Caries
Yes
No
Growth Chart WNL (See Grid)
Brush Teeth Regularly
Yes
No
Comments: ________________________
Dental Visit in the last year
Yes
No
Vision Screen (if indicated)
Not indicated
Hearing Screen (if indicated)
Not indicated
Labs (if indicated)
Not indicated
Subjective: any eye disorder
Yes
No
Subjective: response to voices
Yes
No
Hct or Hgb: WNL
UTD
UTO
Values: _________
F.H. of eye disorder
Yes
No
Delayed speech development
Yes
No
Urine Dipstk: WNL UTD UTO
Wear glasses/contacts
Yes
No
Recurrent O.M.
Yes
No
Comments: _________________
Objective: visual acuity
R 20/__ L 20/__
Hearing 20 db HL (pass or fail)
Lead if indicated (see criteria) ____
1000Hz
2000Hz
4000Hz
with glasses/contacts
Yes
No
Right ear
______
______
______
Muscle balance
pass
fail
Left ear
______
______
______
Color perception
pass
fail
Review of System
WNL
Abnl.
Comments
Objective: PE
WNL
Abnl.
Comments
Constitutional
General Appearance
Eyes
Skin
ENT
Head
CV
Eyes
Respiratory
ENT
GU
Mouth/Teeth
GI
Neck
Musculoskeletal
Chest
Integumentary
Heart
Neuro.
Lungs
Psychiatric
Abdomen
Endocrine
Genitalia (Tanner Stage)
Hemat./Lymphatic
Neurological
Allergic/Immuno.
Musculoskeletal
Social History/Devel. Assessment (Use additional sheets for more info.)
Anticipatory Guidance
Nutritional/Diet _____________________________
Cognitive Devel.
SkinCare/Hygiene ___________________________
Oral/Dental _________________________________
Speech/Lang. Devel.
Behavioral/Devel. ____________________________
Safety _____________________________________
Social/Emot. Devel.
School Status _______________________________
Health/Reproduction _________________________
Health Beh./Habits
High Risk Activities _________________________
(Drugs/ETOH/Tobacco)
Assessment: ________________________________________________________________________________________________
Plan: _______________________________________________________________________________________________________
Follow-up/Resolution:
For Student Athlete Only: Student Sports/Physical Activity Clearance
A. Cleared
B. Cleared after further evaluation/treatment
C. Not cleared for:
Collision
Contact
Non-contact
Medical Provider’s Name (print):_________________________________ Phone #: _(______)______________________
Signature of Medical Provider:
Date:
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