Physical Examination Form - Rockwood School District
ADVERTISEMENT
1ROCKWOOD SCHOOL DISTRICT PHYSICAL EXAMINATION FORM
FOR
KINDERGARTEN • NEW STUDENTS • GRADE 6 • HIGH SCHOOL SPORTS
PLEASE RETURN COMPLETED HEALTH EXAMINATION FORM TO THE SCHOOL NURSE.
ANY QUESTIONS REGARDING COMPLETION OF THIS FORM MAY BE DIRECTED TO THE SCHOOL NURSE.
STUDENT NAME:
DATE OF BIRTH:
GRADE:_________
___________________________________________
_______________
TO BE COMPLETED BY PHYSICIAN
DATE OF EXAM: _____________________
IMMUNIZATIONS (give month/day/year or attach record)
___________________________________________
PHYSICAL
DTP/DTaP ______ _______ _______ _______ _______
Td/Tdap _________
________
_______
_______
Height: _______ Weight: _______ B/P: ____ / ____ Pulse: _____
Polio ______ _______ _______ _______ _______
Eyes: R – 20/ _____, L – 20/ _____ Hearing: _______________
MMR ______ _______ Hep A ______ _______
Scoliosis screening _______________________
Hep B ______ _______ _______
Review of Systems:____________________________________
Varicella ______ _______ or Month & Year of Illness _________
Note any problems: ___________________________________
HIB ______ _______ _______ _______
____________________________________________________
Meningococcal ___________
ORTHOPEDIC EXAM (for PE/sports participation)
HPV ______ _______ _______
Back/Neck/Shoulders/Extremities:
WNL _______________
Other _______________________________________________
If not, please explain: ___________________________________
HISTORY
____________________________________________________
Asthma:
No_____ Yes_____
Recommendation for PE/Sports:
Full / Limited / None
ADHD:
No_____ Yes_____
Clearance withheld until: _________________________________
Chronic Condition/Major Surgeries: (list, give date) ____________
If limitations, please explain: ______________________________
_____________________________________________________
_____________________________________________________
Allergies (list): _________________________________________
SIGNATURE of EXAMINER:________________________
Medications (list): ______________________________________
Name (please print): ____________________________________
ORTHOPEDIC HISTORY (for sports participation)
Address: _____________________________________________
Previous Injury Date, Explain: _____________________________
_____________________________________________________
______________________________________________________
Phone: _______________________________________________
Special Seating Recommendations: ______________________________________________________________________
Medical Treatment Needed at School: _____________________________________________________________________
Other Health Recommendations: ________________________________________________________________________
FOR HIGH SCHOOL SPORTS PARTICIPATION ONLY - Parent’s or Guardian’s permission: I hereby give my consent for the
student to represent his/her school in interscholastic activities, except those stated on the form by the examiner; I also give my
consent for him/her to accompany the team as a member of its out-of-town trips and will not hold the school responsible in
case of accident or injury. I also give consent and authorize the school to obtain, through a physician of its choice, such med-
ical care as is necessary for the welfare of the student, if he/she is injured in the course of school activities.
Signature of Parent _______________________________________________________ Date ________________________
FORM P2880 rev.12/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business