Student Health Record Siena College Page 3
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FORM MUST BE COMPLETED BY A NON-PARENTAL HEALTH CARE PROVIDER
REPORT OF PHYSICAL EXAM
NAME:__________________________________________________________________DOB:___________________________________
Number of years known to examiner____________ HEIGHT: _______________ WEIGHT: _______________
TEMP. ________ PULSE ________ BLOOD PRESSURE ________ HEARING:RIGHT ________ LEFT________ HEARING AID_______
VISION: RIGHT20/ ________ LEFT 20/________ CORRECTED: RIGHT 20/________ LEFT 20/________ GLASSES/CONTACTS _____
NORMAL
ABNORMAL
PLEASE CHECK EACH ITEM:
PLACE ITEM NUMBER BEFORE EACH COMMENT
1. Head, neck, face, scalp
2. Nose and sinuses
3. Mouth and throat
4. Teeth and gingival
5. Ears
6. Eyes (lids, conjunctiva, pupils, etc.)
7. Chest and lungs
8. Heart (estimate of cardiac function)
9. Vascular system (varicosities)
10. Abdomen and Viscera (hernia)
11. Ano-rectal and pilonidal
12. Endocrine system
13. GU system
14. Spine and muscoloskeletal
15. Upper and lower extremities
16. Skin and lymphatics
17. Neurologic
SPECIAL DIETARY REQUIREMENTS: __________________________________________________________________________________
ALLERGIES: _______________________________________________________________________________________________________
MEDICATIONS: ____________________________________________________________________________________________________
SUMMARY OF ABNORMALITIES, RECOMMENDATIONS, INCLUDING EMOTIONAL STATUS:
(Please let us know if you have any concerns, both physical and emotional, about this student, that you would like to share with us)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
TUBERCULOSIS SCREENING
1. Does the student have signs or symptoms of active TB disease ____YES
_____ NO
If NO, proceed to question 2.
If YES, proceed to Page 4, Tuberculosis Testing.
2. Is the student a member of a high-risk group (See criteria on Page 4)
_____ YES
_____NO
If NO, stop. No further evaluation is needed at this time.
If YES, place tuberculin skin test. A history of BCG vaccination should not preclude testing of a member of a high-risk group.
If there is a history of a past positive TB test, a chest x-ray is required; Proceed to Page 4
HEALTH CARE PROVIDER SIGNATURE REQUIRED:
Health Care Provider’s Signature___________________________________________________DATE_________________________________
PRINT NAME ______________________________________________________________________________________________________
ADDRESS__________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
PHONE#____________________________________________________ FAX#__________________________________________________
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Parent category: Medical