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STUDENT PHYSICAL EXAMINATION |
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Student's Full Name: |
Date: |
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Birth Date: |
Age: |
Sex: |
Grade: |
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Parent or Guardian: |
Phone: |
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A. PHYSICAL EXAMINATION |
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CHECK EACH LINE |
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Abnormal or needs follow-up |
Not done |
Comments |
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Skin/Scalp |
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Nutrition |
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Orthopedic - Spine & Limbs |
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Eyes |
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Visual Acuity |
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Ears |
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Auditory Acuity |
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Speech |
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Nose,Throat, Mouth |
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Teeth and Gums |
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Glands, incl.Thyroid |
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Chest, Breasts |
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Heart, Lungs |
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Abdomen |
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Genitalia |
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Allergies |
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Blood Pressure |
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B. LABORATORY |
Blood Type: |
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Hemoglobin: |
Hematocrit: |
Other: |
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C. Check each line |
NO |
YES |
Comments |
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Emotional/Mental/Behavior Problem |
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Physical handicap - Limit Activity |
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Restriction Needed (specific degree - duration) |
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Diabetics |
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Asthma |
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Medication |
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Surgery (if yes, specify) |
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Other Health Problems (specify) |
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D. I certify that this child has received the physical examination recorded above and in my opinion, may be admitted to school. |
Yes |
No |
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Soccer |
Basketball |
Volleyball |
Track |
Softball |
Weight Training |
Martial Arts |
Handball |
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HISTORY OF IMMUNIZATIONS |
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F. Type Vaccine |
Date |
Date |
Date |
Date |
Type Vaccine |
Date |
Date |
Date |
Date |
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DPT |
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MMR |
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DT/ Tetanus |
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Other |
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Polio (Trivalent) |
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Other |
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Examining Physician- Name:_______________________ |
Signature:____________________________ |
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Phone:________________________________________ |
Cellular:______________________________ |
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