Physical Exam Form

PHYSICAL EXAM FORM

Name______Age______Date of Birth______Last First Middle

Address______City______State_____Zip______

Health History Yes No Yes No ______Head or spinal injuries (severe) ______Stomach Ulcer ______Convulsions (fits, epilepsy) ______Rheumatic Fever ______Encephalitis (sleeping sickness) ______Asthma ______Ever confined as a chronic invalid ______Kidney Disease ______Heart Disease ______Suffering from incurable disease ______Tuberculosis ______Permanent defect as a result of ______Syphilis disease/accident ______Gonorrhea ______Diabetes

Explain positive answer: ______

Do you have any pre-existing conditions: If so, please explain: ______

PHYSICAL EXAMINATION

General appearance and development: Good_____Fair_____Poor_____Weight_____Height_____

HEAD: (with/without glasses) Eyes: For distance: R20/_____ L20/_____ Evidence of disease or injury: R______L______Color vision______Horizontal field of vision: R_____ L______Ears: Hearing-20 ft., Right ear ______Left ear ______Mouth ______Throat______THORAX: Heart______Lungs ______If organic disease is present, is it fully compensated:______Pulse: Before exercise______Two minutes rest after exercise ______Blood Pressure (sitting): Systolic ______Diastolic ______ABDOMEN: Scars______Abnormal Masses______Tenderness______Hernia: Yes_____No_____ If so, where______Is trust worn______GENITO-URINARY: Scars______Urethral discharge______Does menstruation period incapacitate her from school duties? ______How many days ______REFLEXES: Rhomberg______Pupillary______Light R______Accommodation R______L ______Knee Jerks: Right normal ______increased______absent______Knee Jerks: Left normal______increased______absent______EXTREMITIES: Upper______Lower______Spine ______

Laboratory Findings (Not required unless indicated by findings in general examination) Urine: Spec. Gr.______Alb.______Sugar______Blood Serology______Chest X-Ray______

Date of Last Tetanus Shot______DOCTOR’S CERTIFICATE This is to certify that I have this day examined this student and find him/her: ______Qualified for club sport participation ______Qualified for all modified physical activity for reasons explained:______

Signature of Examining Doctor______Date______

Address______City______State______Zip______

Phone______