Student Health Examination
Student’s Name_________________________Phone_______________Age__________
Address_____________________________________Birthdate_____________Sex_____
Name of Parent or Guardian_________________________________________________
A. HEALTH EXAMINATION Height_______Weight______Blood Pressure______
| ( )Normal=N Abnormal=A | A | COMMENT: Abnormal Findings, by # | |
| 1. Appearance | |||
| 2.Skin/Nose | |||
| 3. Head/Scalp | |||
| 4. Eyes | |||
| 5. Visual Acuity (R & L) | |||
| 6. Ears | |||
| 7. Auditory Acuity (R & L) | |||
| 8. Nose/Throat | |||
| 9. Mouth, Teeth and Gums | |||
| 10. Chest / Lungs | |||
| 11. Heart | |||
| 12. Abdomen | |||
| 13. Muscular-Skeletal | |||
| 14. Neurological | |||
| 15. Alertness | |||
| 16. Emotional/Mental Behavior | |||
| 17. Handicap Physical /other specify | |||
| 18. Activity Restrictions (Specify) | |||
| 19. Abuse, substance/physical/emot. | |||
| 20. Nutrition | |||
| 21. Other |
B. HEALTH HISTORY (Serious Illnesses/Injuries: explain) _____________________________
______________________________________________________________________________
(Attach narrative if additional space needed)__________________________________________
C. LABORATORY (AS INDICATED) Hemoglobin__________Urinalysis________________
______________________________________________________________________________
Name____________________________________Title_________________________________
Address_______________________________________________________________________
(Please Print)
Authorized Signature________________ Date __________
