PRIVATE PHYSICIAN'S REPORT OF PHYSICAL EXAMINATION …
Elizabethtown Area School District PRIVATE PHYSICIAN'S REPORT OF PHYSICAL EXAMINATION OF SCHOOL AGED STUDENT
Please return form to student's school c/o School Nurse or fax directly to nurse's office
Parent/Guardian/Student: Please complete boxes #1 and #2 before the student's exam. Take all forms to appointment. Your medical provider will complete boxes #3-#6 and sign the bottom of the exam.
Student's name:
Grade: ____________ Today's date: ____________
Last
First
Middle Initial
Date of birth:
Age at time of exam: ___________________ Gender: Male Female
#1 Medicines and Allergies:
Medication: Please list all prescription and over-the-counter medicines and supplements the student is currently taking: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Allergies: Does the student have any allergies? No Yes (If yes, list specific allergy, severity of reaction and history of exposure) Insect sting Peanut/nut Latex Shellfish Environmental/Seasonal Animal/Pet Medication Other __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Is emergency medication prescribed? No Yes (If yes, please list the allergen, the medication name, dose, time, route and reason below) __________________________________________________________________________________________________________________
#2 General Student Health:
Yes No
Are there any ongoing/chronic medical conditions? If so, please list:
______________________________________________________________________________________________________
Has the student... Ever had surgery? If so, please list the surgery and when.
Yes No
Ever had a major illness requiring hospitalization? If so, please list what and when.
Ever been treated for asthma?
Ever used an inhaler or taken asthma medicine?
Ever had a cough, wheeze, difficulty breathing, shortness of breath or felt lightheaded DURING or AFTER exercise?
Had discomfort, pain, tightness or chest pressure during exercise?
Has the student...
* If yes, please explain, including when the injury occurred. *Yes No
Ever had a head injury or concussion
Had a broken/fractured bone or dislocated joint?
Had an injury to a muscle, ligament or tendon?
Had an injury that required a brace, cast, crutches, or orthotics?
#3 Immunization Boosters and Tests Done: Health Care Providers: Please photocopy immunization history from student's medical record - or - insert information below
Vaccine
Diphtheria.Tetanus/Pertussis (child)
Type: DTaP, DTP or DT
Diphtheria.Tetanus/Pertussis (adolescent/adult)
Type: Tdap or Td
Polio:
Type: OPV or IPV
Hepatitis B (HepB)
Measles/Mumps/Rubella (MMR)
Varicella:
Vaccine Disease
Meningococcal Conjugate Vaccine (MCV4)
Human Papilloma Virus (HPV)
Type: HPV2 or HPV4
Hepatitis A (HepA)
Other Vaccines: (Type and Date)
Document: (1) Type of vaccine; (2) Date (month/day/year) for each immunization
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Student's name:
Date of birth: _____________________ #4 Current list of medical/psychological diagnoses
#5 Physical Assessment and Findings
Physical exam for grade:
K/1 6 11 Other
Height: (
) inches
Weight: (
) pounds
BMI: (
) raw score
BMI-for-Age Percentile: (
)%
Pulse: (
)
Blood Pressure: (
/
)
CHECK ONE NORMAL *ABNORMAL
DEFER
*ABNORMAL FINDINGS/RECOMMENDATIONS/REFERRALS
Head/Hair/Scalp
Skin
Eyes/Vision
Corrected
Ears/Hearing
Nose and Throat
Teeth and Gingiva
Lymph Glands
Heart
Lungs
Abdomen
Genitourinary
Neuromuscular System
Extremities
Spine (Scoliosis)
Other:
#6 Medical Conditions or Chronic Diseases Medical conditions or chronic diseases which require medication, restriction of activity or which may effect education
Physical exam performed at: Personal Health Care Provider's Office School
Exam Date: _____________________
Examiner Signature: ___________________________________________________ MD DO
PAC
CRNP
Print Examiner Name: __________________________________________________Phone Number: ________________________ Place of examination: ___________________________________________________ Fax Number: __________________________
Rev 3/2013 Adapted in part from the Pennsylvania Department of Health Bureau of Community Health Systems Division of School Health Private or School Physical Examination of School Age Student Form.
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