Health Services/health Appraisal Form printable pdf download

Health Services/health Appraisal Form

Union County TEAMS Charter School and High School/College Academy

20__ - 20___ HEALTH SERVICES/HEALTH APPRAISAL FORM

Name: ______________________________________

Date of Birth: _________________

Dear Parent/Guardian: __________________________________________________________

NOTE: ALL PHYSCIALS MUST BE CURRENT. Please present this form to your

physician at the time of your examination. Upon completion, please return to the school.

(ATTACH UPDATED IMMUNIZATION RECORD)

HEIGHT: _______ WEIGHT: _______ B.P.: _______ PULSE: _______ URINE: _______ PROTEIN: _______ SUGAR: _______

VISION: RIGHT: _______ LEFT: _______ BOTH: _______

GLASSES: RIGHT: _______ LEFT: _______ BOTH: _______

PHYSICAL FINDINGS

NORMAL

ABNORMAL

SPECIFY AND RECOMMEND

EYES

VISION

COLOR PERCEPTION

EARS – OTOSCOPIC

HEARING: RIGHT

HEARING: LEFT

TEETH/MOUTH

NOSE

THROAT

LYMPH GLAND

THYROID

HEART

LUNGS

ABDOMEN

HERNIA

GENITO-URINARY

ORTHOPEDIC (STRUCTURAL)

SCOLIOSIS SCREENING

SKIN

NUTRITION

NERVOUS SYSTEM

SPEECH

OTHER

-over-

Pg 1of 2

Health Services/health Appraisal Form