Student Physical Examination Form - Student Physical Examination Form printable pdf download

Student Physical

Examination Form

To be completed by Healthcare Provider for all New Students,

Kindergarteners, and every other year for Gr. 6-12 Athletes

Date of Physical Exam:____________________________

___________________________________________________________________________ _______ _______ ___________________ _______

Student Name

Sex

Age

Date of Birth

Grade

Height:________________ Weight________________ BP:_________ P: _________ R:________ Last Tetanus (date)?______________________

Medications: ____________________________________________________________________________________________________________

Allergies (foods, insects, drugs, latex):_________________________________________________________________________________________



HEALTH NEEDS IN SCHOOL

This student has the following problems, which may adversely affect his or her education experience (explain below):

 Cardiac

 Chronic Disease

 Physical Dysfunction

 Hearing

 Vision

 Speech/Language

 Behavioral/Social/Emotional/Psychiatric

Is this student on long-term medication  Yes  No Please specify: ______________________________________________________________

Does this student have the knowledge and skill to carry and self-administer this medication?

 Yes  No

 Please attach an EMERGENCY ACTION PLAN for the following conditions:

 Anaphylaxis (food/sting allergy)

 Asthma

 Diabetes

 Seizure

 Other: ____________________________________________

Comments and recommendations (additional information about any of the above conditions/assessments): ___________________________________

_______________________________________________________________________________________________________________________



IMMUNIZATIONS:

Up-to-date?  Yes  No

 Please attach a complete Immunization record.

 Medical Exemption: This student has not received immunizations for medical reasons (specify immunizations):

_______________________________________________________________________________________________________________

 Permanent

 Temporary

(Please specify plan for immunization)______________________________________________________

_______________________________________________________________________________________________________________



HEALTH CARE PROVIDER’S REVIEW

I have reviewed the data above, reviewed the student’s medical history and make the following recommendations for his/her participation in the

school program/athletics/physical education:

 CLEARED WITHOUT RESTRICTIONS: This student may participate fully in the school program, including physical education, activities,

sports, and co-curricular activities.

 Cleared AFTER further evaluation or treatment for____________________________________________________________________

 Cleared for LIMITED PARTICIPATION: Reason(s) and explanation:________________________________________________________

_____________________________________________________________________________________________________________

 NOT CLEARED FOR PARTICIPATION: Reason(s) and explanation:________________________________________________________

_____________________________________________________________________________________________________________

__________________________________________________________________ ___________________________________________________

Health Care Provider’s signature

Date

__________________________________________________________________ ___________________________________________________

Health Care Provider’s name (print)

Name/Group Practice (print)

Greater Portland Christian School, 1338 Broadway, South Portland, ME 04106

Voice (207) 767-5123  Fax (207) 767-5124  office@gpcs.net

20161014

Student Physical Examination Form - Student Physical Examination Form

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