School Medical Report Form

   

   

 

WAUKEE   C OMMUNITY   S CHOOL   D ISTRICT    

MEDICAL   R EPORT  

 

Student   N ame____________________________________________________         G ender     M       F           B irthdate   _ ________________  

Parents/GuardianName__________________________________________________________________________________________  

Address_____________________________________________________     C ity____________________________     S tate______________    

School   o f   A ttendance___________________________________________________     G rade     _ ____________  

 

SIGNIFICANT   H EALTH   H ISTORY  

Yes  

No  

 

Yes  

No  

 

 

 

Asthma  

 

 

Hospitalizations   ( List   B elow)  

 

 

Seizure   D isorder  

 

 

Surgeries   ( List   B elow)  

 

 

Diabetes  

 

 

Allergies      

 

 

Heart   D isorder  

 

 

 

Pleurisy/Pneumonia  

 

 

Rheumatic   F ever  

 

 

Scarlet   F ever  

 

 

Medications  

 

 

Eczema  

 

 

 

Meningitis  

 

 

Chicken   P ox  

 

 

Other   ( List   B elow)  

 

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________  

 

PHYSICAL   E XAMINATION   /   P HYSICIAN   R EPORT                

X   =   N ormal     o r  

 

R

 

ESULTS

Negative  

 

Appearance  

Height     ( Required)  

 

 

Posture  

Weight   ( Required)  

 

 

Nutrition  

Blood   P ressure   ( Required)  

 

 

Development  

Hemoglobin  

 

 

Neurological  

Urinalysis  

 

 

Speech   D efect   Blood   L ead   L evel   ( Required)  

                                      u g/dL         D ate   C ompleted________________  

 

Hair   /   S calp  

Hearing     S creening     ( Required)   Referral       Y es________             N o_________  

 

Nose  

Vision   S creening   ( Required)  

R                   / 20                       L                     / 20                       B oth                     / 20  

Referral       Y es_________           N o   _ _________  

 

Ears  

 

Throat  

Chronic   D isease  

 

 

Thyroid  

Physical   E ducation  

Full   _ _______             L imited   _ _______           N one   _ ________  

 

Lymph   N odes  

Anatomical   R estrictions  

 

 

Heart  

Physician’s   C omments   a nd   R ecommendations  

 

Lungs  

 

Extremities  

 

Abdomen  

 

Skin  

 

Hernia  

 

Back  

 

 

Physicians   S ignature__________________________________________________     D ate   o f   E xam________________