|
Health Care
Provider’s Examination |
Name
_______________________________________ o
Male o
Female Date of Birth
_____________________
Medical
History__________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________________________________________________________________
Y N
o
o Allergies:
Please list: Medications
__________________ Food ______________ Other
___________
History of Anaphylaxis to _______________________ Epi-Penâ: o Yes o No
o o Asthma: Asthma Action Plan o Yes o No (Please attach)
o o Diabetes: o
Type I o
Type II
o o Seizure
Disorder: ___________________________________________________________________
o o Other (Please
specify) _______________________________________________________________
Current
Medications
(if relevant to the student’s health and safety) Please circle those
administered in school;
a separate medication order form is
needed for each medication administered in school.
Physical
Examination Date
of Examination: ___________________________________
Hgt: _________(_____%) Wgt:
________(______%) BMI: ________(_____%) BP: ______________
(Check
=
o General _____________ o Lungs ___________ o Extremities ___________
o Skin ________________ o Heart ____________ o Neurologic
___________
o HEENT _____________ o Abdomen _________ o Other _______________
o Dental/Oral __________ o Genitalia __________
Screening: Pass Fail Pass Fail Pass Fail
Vision: Right Eye o o Hearing: Right Ear o o Postural
Screening: o o
Left Eye o o
Left Ear o o
(Scoliosis/Kyphosis/Lordosis)
Stereopsis o o
Laboratory
Results: o Lead ___________ Date __________ o
Other __________________________________
The entire examination was normal: o
Targeted TB Skin Testing: o Med-to-High risk (exposure to TB; born, lived,
travel to TB endemic countries, medical risk factors):
Date of PPD: __________ Results: _____mm.
Referred for evaluation to:
__________________________________ o Low risk (no PPD done)
________________________________________________________________________________________________
This student has the following problems that may
impact his/her educational experience:
o Vision o Hearing o Speech/Language o Fine/Gross Motor Deficit
o Emotional/Social o Behavior o Other
Comments/ Recommendations:
______________________________________________________________________
________________________________________________________________________________________________
o Y o N This student may
participate fully in the school program, including physical education and
competitive
sports. If no, please list restrictions: _________________________________________________
o Y o N Immunizations are
complete. If no, give reason: Please attach
System Certificate or other complete immunization record.
__________________________________________
_________
_______________________________________
Signature
of
____________________________________________________
Group
Practice
______________________________________________________________________________________________
Address City State Zip
Code
Please
attach additional information as needed for the health and safety of the
student.
MDPH