Physical Examination Form Page 2
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2PHYSICAL EXAMINATION FORM
Student please print name clearly below
Last:
First:
DOB:
/
/
TO BE COMPLETED BY PHYSICIAN
Height ______/_____
Vision: O.D._______________________O.S.__________________________
Weight____________lbs.
Blood Pressure:____________________mmHG
PPD
Date:_____________________________Result________________________
Chest X-Ray
Date:_____________________________ Result________________________
(if PPD is Positive)
LAB WORK:
Hct:____________
Urinalysis:
Glucose______________________Protein_______________________
RECOMMENDED FOR STUDENTS OVER 40: EKG__________
Chemistry_____________
SIGNIFICANT MEDICAL HISTORY _______________________________________________________________________________
_________________________________________________________________________________________________________________
YES
NO
DESCRIBE
1. Head, Ear, Nose or Throat
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Hernia
6. Eyes
7. Genitourinary
8. Musculoskeletal
9. Metabolic/Endocrine
10. Neuropsychiatric
11. Skin
12. Allergies
Depression Screening
Done
Not Done
COMMENTS__________________________________________
Do you have any recommendation regarding the care of this student?
Yes
No
If yes, describe briefly______________________________________________________________________________________________
Is the student now under treatment for any medical or emotional condition?
Yes
No
If yes, describe briefly______________________________________________________________________________________________
RECOMMENDATION for Health & Physical Education class:
Full Activity
Modified Activity
No Activity
Restrictions/Precautions: Explain______________________________________________________________________________________
RECOMMENDATION to Participate in Competitive Athletics:
Full Activity
Yes
No
Restrictions:
Explain_____________________________________________________________________________________________
Physician’s Signature_____________________________________________________________
Address________________________________________________________________________
Telephone No.__________________________________________________________________
CLINIC STAMP REQUIRED BELOW
Date________________________________________
Revised on 08/21/12
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Parent category: Medical