TEANECK PUBLIC SCHOOLS School Health Services

Physical Examination

Student’s name: Parent/Guardian name: Phone #:
Health Care Provider: Address:

Age: Address: School: Phone:
City/State/Zip:

DOB:	Sex:

Grade: Fax:

PHYSICIAN / HEALTH CARE PROVIDER – PLEASE COMPLETE BOTH SIDES OF FORM

Exam Date:	Height:	Weight:	BP:	Pulse:

Vision: R 20/	L 20/	Corrected:	Y	N	Glasses:	Y	N	Hearing:	R	L

	Normal
	Abnormal Findings
	Comments
	
General Appearance
				
Head/Neck
				
Eye/Sclera/Pupils
				
Ears:
				
Gross Hearing
				
Nose/Mouth/Throat
				
Lymph Glands
				
Heart: Murmurs/Rhythms
				
Lungs: Auscultation/Percussion
				
Chest Contour
				
Skin
				
Abdomen:
Assessment (inc. liver/spleen)
				
Tanner Stage:
Testes/Onset of Menses
				
Hernia
				
Neck/Back/Spine: Range of motion
				
Scoliosis
				
Upper Extremities
				
Lower Extremities
				
Neurological:
Balance & Coordination Romberg
				
Evidence of Marfan Syndrome

Most recent Immunizations / Dates:

Medications currently in use:

Additional Observations / Comments:

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01/2017

HISTORY: Please indicate all areas where disease or alterations have occurred and explain below: Allergies/Anaphylaxis	Eczema / Skin	Hospitalizations / Surgery

Asthma / Respiratory Cardiovascular / Murmur Childhood diseases

Endocrine Gastrointestinal Genitourinary

Musculoskeletal Neurological / Seizures Other

Explanation/Comments:

ACTIVITY CLEARANCE:

A.	Student may participate in physical education and all sports:	YES	NO

B.	Cleared after completing evaluation for:

C.	NOT CLEARED FOR: (check all that apply)

Collision Strenuous

Contact Moderate

Non-Contact Non-Strenuous

Diagnosis:

Recommendations:

VACCINATIONS:
	Date
	Date
	Date
	Date
	Date
	
DPT / DTaP
						
Tdap
						
OPV / IPV
						
MMR
						
Measles
						
Mumps
						
Rubella
						
Hepatitis A
						
Hepatitis B
						
HIB / Prohibit
						
Varicella
						
Pneumococcal (PCV7)
						
Meningococcal
						
Influenza
						
Other:
						
Other:

LEAD SCREENING:	Date test performed:	Result:

TUBERCULOSIS TESTING: Mantoux:	Date planted:
Date planted:

Date read: Date read:

Result: Result:

Chest X-ray INH Therapy:

Date:
Date started:

Result:
Dosage:	Duration of Tx:

Physician / HCP Signature	Date	Stamp