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.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download