School Health Physical Form
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2School Health Physical Form
Top Knowledge Healthcare Institute
19 East Fayette Street, Suite 401
Baltimore, MD 21202
Phone:410-528-1600|Fax:410-528-1663
Section A (REQUIRED): Print legibly in blue or black ink
First Name
Middle Name
Last Name
Social Security Number
Date of Birth
Place of Birth
Age
Sex
Local Address
Phone Number
Email Address
Emergency Contact
Relationship
Home Number
Cell Number
Work Number
Section B (REQUIRED): Print legibly in blue or black ink
Physical Examination
Height:
Weight:
Pulse:
Respiration:
Blood Pressure:
Normal
Abnormal Findings: (Please explain)
General Appearance
Head/Face/Scalp
Mouth/Throat
Eyes/Ears/Nose
Lungs/Chest
Heart
Pulses
Abdomen
Genitourinary
Musculoskeletal
Neurological
Deep Tendon Reflexes
Skin/Hair
Mental Health
Physical Requirements: All students will be required to meet the same physical demands as are required by
employees of the clinical site facility. This may include, occasional and even prolonged physical activity, such as
.
walking, standing, sitting, and lifting as much as 50 pounds or more
☐
Cleared to begin the Certified Nursing Assistant program without any restrictions
☐
Not Cleared to begin the Certified Nursing Assistant program without any restrictions
I have examined the above-named student and have completed the health form. The student does not
present with any contraindications that will limit their ability to participate in the Certified Nursing
Assistant program.
Name of Provider (title): ______________________________ Phone Number:________________
Address: ______________________________________________________________________
Signature of provider: ______________________________________ Date: _________________
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Parent category: Medical