Student Physical Examination Form Page 2

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C. Health History - Any “Yes” response requires an explanation.
Yes
No
1. Does student require any modifications or restrictions of school
program, including physical education or sports?
2. Does student require any special protective equipment for
physical education or sports?
3. Is there a current health problem of which the School Health and
Physical Education Staff should be aware?
4. Is there any past history of serious illness, injury, or operation?
5. Is there any family history of genetic condition or disease?
6. Does the student have any allergic conditions?
7. Does the student require any medication or treatment for a health
condition? If medication or medical treatment is required, a Doctor's
order must be provided. The child's parent/guardian is to contact
the School Health Office for the necessary forms.
Explanation (if any “Yes” response checked above)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Recommendations, if any:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Date ________
Signature of Physician _______________________________________________________
Physician’s Name and Address - PLEASE PRINT
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Date ________
__________________________________________________________________________
Approved by School Medical Inspector

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