Private Physical Examination Form For School Page 2
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2Significant Medical Conditions ( )
If Yes, Explain
Yes
No
Allergies .....................................
Asthma.......................................
Cardiac ......................................
Chemical Dependency ..............
Drugs .........................................
Alcohol .......................................
Diabetes Mellitus .......................
Gastrointestinal Disorder ...........
Hearing Disorder........................
Hypertension..............................
Neuromuscular Disorder............
Orthopedic Condition .................
Respiratory Illness .....................
Seizure Disorder ........................
Skin Disorder .............................
Vision Disorder ..........................
Other (Specify)...........................
Are there any special medical problems or chronic diseases which require restriction of activity, medication or
which might affect his/her education? If so, specify
Report of Physical Examination ( )
Normal
Abnormal
Not Examined
Comments
Height (inches)
Weight (pounds) BMI
Pulse (
)
Blood Pressure
Hair/Scalp
Skin
Eyes/Vision
Ears/Hearing
Nose and Throat
Teeth and Gingiva
Lymph Glands
Heart – Murmur, etc
Lung – Adventitious Finding
Abdomen
Genitourinary
Neuromuscular System
Extremities
Spine (Presence of Scoliosis)
Date of Examination
Signature of Examiner
PRINT Name of Examiner
Address
Telephone Number
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