Students Medial History Form - Department Of Health, The City Of New York Page 2

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TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
CLINICIAN’S COMMENTS:
Perforated ear drum or “tubes” in ears?
Yeso
Noo
_________________________________
Draining ears?
Yeso
Noo
_________________________________
Have you ever had:
Sinus problems or hay fever?
Yeso
Noo
_________________________________
Braces or removable false teeth?
Yeso
Noo
_________________________________
Have you ever had:
Any broken bones?
Yeso
Noo
_________________________________
Dislocation or other serious problems?
Yeso
Noo
_________________________________
Serious foot problems?
Yeso
Noo
_________________________________
Back injury or frequent backaches?
Yeso
Noo
_________________________________
Ankle or knee injury or problem?
Yeso
Noo
_________________________________
Other joint problems?
Yeso
Noo
_________________________________
Do you have a hernia?
Yeso
Noo
_________________________________
Boys: Any problems with testicles?
Yeso
Noo
_________________________________
Girls: Any menstrual problems?
Yeso
Noo
_________________________________
Age at first menstrual period?_______
Do you miss school because of your period? Yeso
Noo
_________________________________
Have you ever had:
Diabetes?
Yeso
Noo
_________________________________
Single illness for more than 10 days?
Yeso
Noo
_________________________________
Any operations?
Yeso
Noo
_________________________________
Easy bruising or bleeding tendency?
Yeso
Noo
_________________________________
Anemia?
Yeso
Noo
_________________________________
Asthma?
Yeso
Noo
_________________________________
Bee sting allergy?
Yeso
Noo
_________________________________
Other allergies (food or medication)
Yeso
Noo
_________________________________
Heart trouble or murmurs?
Yeso
Noo
_________________________________
High blood pressure?
Yeso
Noo
_________________________________
Cough lasting more than 3 weeks?
Yeso
Noo
_________________________________
Chest pain or faintness with exercise?
Yeso
Noo
_________________________________
Cough lasting more than 3 weeks?
Yeso
Noo
_________________________________
Chest pain or faintness with exercise?
Yeso
Noo
_________________________________
Kidney problems?
Yeso
Noo
_________________________________
Skin infection?
Yeso
Noo
_________________________________
Do you take any medicines?
Yeso
Noo
_________________________________
Do you smoke?
Yeso
Noo
_________________________________
Have you ever been told not to play any sport
Because of your health?
Yeso
Noo
_________________________________
PHYSICAL EXAMINATION
THIS SECTION IS TO BE COMPLETED BY PHYSICIAN
HEIGHT: ___________
WEIGHT: ___________
PULSE: _____________
BLOOD PRESSURE: ________________
VISION UNCORRETED: L20/ ________
R20/ ________
CORRECTED: L20/_______
R20/________
NORMAL
ABNORMAL
COMMENTS
Skin
o
o
_________________________________
Eyes
o
o
_________________________________
ENT
o
o
_________________________________
Mouth & Teeth
o
o
_________________________________
Cardiovascular
o
o
_________________________________
Lungs, Chest
o
o
_________________________________
Spine
o
o
_________________________________
Abdomen
o
o
_________________________________
Genitalia (Hernia)
o
o
_________________________________
Tanner Stage
o
o
_________________________________
Extremities
Orthopedic
o
o
_________________________________
Neuromuscular
o
o
_________________________________
Assessments:
Plan:
__________________________________
(CLINICIAN’S SIGNATURE)
STAMP & SIGN

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