Health Appraisal Form
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2East Brunswick Public Schools
East Brunswick, New Jersey 08816
Student Services
Health Appraisal Form
Student Name: ______________________________ Date of Birth: ___________
School: ___________________________________ Date: __________________
School Address: ______________________________________________________
Dear Parents:
Please present this form to your physician at the time of your child’s examination.
Upon completion, return to the school nurse at the school’s address given above.
Thank you.
Height: ____ Weight: _____B.P.:______ Pulse: ______ Urine-Protein: ______ Sugar:
______
Vision-Right: _____Left: _____Both: ______ Glasses-Right: ______ Left: ______ Both:
______
Please indicate with a √
Physical Findings
Specify and Recommend
(check)
In the appropriate column.
Normal
Abnormal
EYES
VISION
COLOR PERCEPTION
EARS - OTOSCOPIC
HEARING
Left
Right
TEETH/MOUTH
NOSE
THROAT
LYMPH GLANDS
THYROID
HEART
LUNGS
ABDOMEN
HERNIA
GENITO-URINARY
ORTHOPEDIC
(STRUCTURAL)
SCOLIOSIS SCREENING
SKIN
NUTRITION
NERVOUS SYSTEM
SPEECH
OTHER
GENERAL APPEARANCE
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