Primera Iglesia Bautista de Ceiba

LIGHTHOUSE BAPTIST ACADEMY
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 __________

Lighthouse Baptist
Academey of Ceiba

A ministry of Primera Iglesia
Bautista de Ceiba, PR 00735
(787) 885-3755

Lighthouse Baptist Academey of Ceiba

A ministry of Primera Iglesia Bautista de Ceiba, PR 00735 (787) 885-3755

Lighthouse Baptist
Academey of Ceiba

A ministry of Primera Iglesia
Bautista de Ceiba, PR 00735
(787) 885-3755