Student Physical Examination Form

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Flemington - Raritan Regional Schools
Student Physical Examination Form
Preschool –Grade 4
Student Name
Date of Birth ______ Grade
Type of Physical ( √ ) Kindergarten ___ New Student ___ Grade ___ Sports ___
A. Immunizations - Complete all dates.
DTaP/DPT/Tdap
(specify)
OPV/IPV (specify)
MMR
Measles
____________
____________
Mumps
____________
____________
Rubella
____________
____________
Varicella
HIB
Hepatitis B
Pneumococcal
Meningococcal
Influenza
Mantoux
Date given
Date read
Result
B. Date of Physical Examination
___________
Height ______
Weight _____
BP _______
Check one (√ )
Normal
Deviation
Explanation
Ears (otoscopic)
audio R____ L ____
Eyes
acuity R ____ L ____
Lymph Glands
Thyroid
Nose
Throat
Teeth-Mouth
Heart
murmur _______
Lungs
Abdomen
Hernia
Genito-Urinary
Orthopedic:
Structural
Posture
Scoliosis
Feet
Skin (Non-communicable)
Nutrition
Nervous System
Speech
Other
General Appearance
(Continued on Back)

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