PHYSICIANS EXAMINATION FORM

Name__________________ Date of Birth_____________Grade____

Illness:(Childhood Diseases, Operations, Fractures, etc.)please list:______________________________________________________

Last DPT Immunization__________, Polio Booster__________, MMR Booster_______
Hepatitis B Series__________, Varivax__________ Mantoux Text (required for Admission)
Date:__________, Result:__________

Height:__________, Weight:__________

	Normal	Abnormal/Specify
Blood Pressure and Pulse	______________________________________________
A/R	______________________________________________
Skin	______________________________________________
Eyes	______________________________________________
Ears	______________________________________________
Nose	______________________________________________
Throat	______________________________________________
Teeth/Mouth	______________________________________________
Heart	______________________________________________
Lungs	______________________________________________
Abdomen	______________________________________________
Hernia	______________________________________________
Urine Analysis	______________________________________________
Blood Work	______________________________________________
Nervous System	______________________________________________
Nutrition	______________________________________________
Orthopedic Defects	______________________________________________
Scoliosis Screening	______________________________________________

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May this student participate in a complete school program?
Yes_______, No_______, Reason_________________________________

May this student participate in competitive sports?
Yes_______, No_______, Reason_________________________________

Is this child taking any medication? Yes_______, No_______, Any Allergies Yes____, No______
If yes, please list below
___________________________________________________________________________________
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PRINT-Physicians Name_________________________ Physicians Signature_________________________

Date of Examination____________________ Today's date (if different)____________________