Student Medical Report Form - North Carolina Page 2
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1
2TO BE COMPLETED BY PHYSICIAN OR OTHER APPROPRIATE HEALTH CARE PERSON
I have reviewed the history on the reverse side if applicable __________
Please check any of the following illness or behaviors the child has or has had:
o
o
o
o
Asthma
Cerebral Palsy
Ear Infections
Skin Conditions
o
o
o
o
Bleeding Conditions
Convulsions / Seizures
Hearing Difficulties
Speech Difficulties
o
o
o
o
Bone/Muscle Conditions
Cystic Fibrosis
Heart Conditions
Stomach Aches
o
Bowel Difficulties
o
Dental Conditions
o
Meningitis
o
Cancer/Leukemia
o
Diabetes
o
Sickle Cell Anemia
Allergies: (List) _________________________________________________________________________
Other: (List) ___________________________________________________________________________
Height: _____ ft. _____ in. _____ percentile
Weight: _____ lbs. _____ percentile
Blood Pressure ___________
With corrective lenses o Yes o No
Normal o
Abnormal o
1. Vision
2. Hearing (Gross)
R
L
Both
Far
20/
20/
20/
Near
20/
20/
20/
Please check or note problems below:
o
Abdomen
o
Flexibility
o
Knees
o
Neurologic
o
Back
o
Genitalia
o
Lungs
o
Ears, Nose, Throat
o
Head
o
Lymphatic
o
Extremities
o
Heart
o
Neck/Shoulder
Positive Findings:
Laboratory Results (if indicated): Normal
Abnormal
o
o
Urine
o
o
Hemocrit
TB Tine
o
o
If asthma was checked, is an inhaler used during/prior to athletic participation: yes _____ no _____
Comments: _______________________________________________________________________________
Protective equipment (beyond what is required by sport): _________________________________
Review by physician
___________________________ Full, unlimited participation
___________________________ Limited participation
Limitations: ____________________________________________________________________
______________________________________________________________________________
Immunizations (To be completed only by doctor or other appropriate health care personnel):
Record of Immunization (enter date of EACH dose – Mo/Day/Year)
Vaccine
#1
#2
#3
#4
#5
DTP
DT
OPV
HIB
HEPB
MMR
VAR
Other
I CERTIFY THIS CHILD HAS RECEIVED THE IMMUNIZATIONS AS NOTED ABOVE.
PHYSICIAN’S SIGNATURE ______________________________________ TITLE: ____________________ DATE: __________
Address: ______________________________________________________ Phone: _________________
Exemptions from N.C. State law require that a statement must be on file at school in student’s permanent record. Medical_____Religious____
over
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