Student Medical Report Form - North Carolina
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1Student Medical Report
To Be Completed by Physician or Other Appropriate Health Care Person
Child’s Name __________________________________________________________________________
(Last)
(First)
(Middle)
(Nickname)
Birth date _____________
Sex (male or female) _________________________
Name of Parent(s)/Guardian(s) _______________________ Phone (h) ____________ (w) ___________
________________________________________________ Phone (h) ____________ (w) ___________
Height: _____ ft. _____ in. _____ percentile
Weight: _____ lbs. _____ percentile
Blood Pressure _____
2. Hearing (Gross) Normal o
Abnormal o
1. Vision
R
L
Both
Far
20/
20/
20/
Near
20/
20/
20/
With glasses
o
Yes
o
No
Please check any of the following illness or behaviors the child has or has had:
___ Asthma
___ Cystic Fibrosis
___ Hearing Difficulties
___ Bleeding Conditions
___ Cerebral Palsy
___ Meningitis
___ Bone/Muscle Conditions
___ Dental Conditions
___ Sickle Cell Anemia
___ Bowel Difficulties
___ Diabetes
___ Skin Conditions
___ Cancer/Leukemia
___ Ear Infections
___ Speech Difficulties
___ Convulsions/Seizures
___ Heart Conditions
___ Stomach Aches
Allergies: (List) _________________________________________________________________________
Other: (List) ___________________________________________________________________________
Physical Exam: To Be Completed by Physician
___ Head
___ Genitalia
___ Nose
___ Lungs
___ Eyes
___ Heart
___ Extremities
___ Throat
Positive Findings:
Laboratory Results (if indicated): Normal Abnormal
Urine
o
o
Hemocrit
o
o
TB Tine
o
o
Any previous hospitalizations or operations? No ___ Yes ___ If yes, when and for what reason? ________
______________________________________________________________________________________
Should activities be restricted? _____________________________________________________________
______________________________________________________________________________________
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: __________
Exemptions from N.C. State law require that a statement must be on file at school in student’s permanent record.
Medical_______Religious___________
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