3.  Recommendation for Physical Examination of Students

(Refer to Administrator’s Manual Policy #4701)

 

     The physical exam requirements recommended by the St. Louis Archdiocese and the Health advisory for the 2009-2010 school year are as follows:

     Entrance to kindergarten, grades 3 and 6 and all newly enrolled students. 

 

    This or any form used by your physician is acceptable.

  

 

                          

Immunization Record

List dates (month-day-year)

 

Type of vaccine	1st	2nd	3rd	4th	5th
DTaP/DTP (Diphtheria, Tetanus, Pertussis)
DT
Td
OPV/IPV (polio)
MMR (Measles, Mumps, Rubella)
Measles
Mumps
Rubella
HIB
TB Test (type & result)
Hepatitis B
Varicella (chicken pox vaccine)
Hepatitis A* *not required as of 2001 Other:

 

Follow-Up Notes:

 

 

 

 

 

 

 

 

 

Physical Examination Form

 

                                                                        Name: _______________________________

 

Birth Date: _________________ Sex: _______

 

   Parent/Legal Guardian: __________________

 

   Physician’s Name: _______________________

 

Physician’s Phone #:_____________________

 

To Parent/Legal Guardian:

 

            In accordance with the recommendations of the St. Louis Archdiocese Health Advisory Committee, all children are expected to have a complete physical examination upon entrance to school, kindergarten, 3rd grade, 6th grade, and all newly enrolled students. 

 

            This form is provided for the convenience of your child’s physician.  At the time of the examination, please have your physician complete and sign this form.  It is expected that each student have this form on file at school by the first day of school.         

 

 

School Name: ___________________________

School Address: _________________________

School Phone: __________________________

 

Medical History: (To be completed by parent)

 

Eyes: Glasses___ (reading____ distance____) Contacts_____ other ____________________________________________________

Ears: frequent infections______________________ tubes_____

Hearing difficulty (explain) ________________________________

Hearing aid - right_____ left______ wear at school_____

 

Allergies: (drugs, food, insects, pollens) 

Please list: _______________________________________________ has the allergy ever required emergency action? (Explain) __________________________________________________________

 

Asthma: Yes_____ No_____ Triggered by: ___________________ Treatments/Medications: __________________________________ Diagnosed by physician (date): ___________________

 

Seizures: Yes_____ No_____ Date of last seizure: ______

Describe seizure: __________________________________________ Medication: _______________________________________________

 

Other Medications/Inhaler: _________________________________

____________________________________________________________

Reasons for taking: _________________________________________

 

Other Health Concerns:  diabetes____ heart problem____ bleeding_____ eating_____ sleeping____ bowel____ bladder____ bed wetting____ dental_____ skin____ menstrual history_____ phobias (fears) _____ blood pressure____ orthopedic____ neurological____ head aches____ blood disorder____ lungs____

Sickle cell anemia_____ TB exposure_____

EXPLAIN: _______________________________________________________________________________________________________________

____________________________________________________________

Other illness, injury, or health problem that might affect performance at school: ____________________________________________________________Physical Examination: (To be completed by                                                                   physician)

Growth Measurements:

Height: __________   Weight: ___________

Dietary restrictions: _____________________________________

 

Physiologic Measurements:

Temp: ________   Pulse: __________   Respiration: __________

Blood Pressure: __________   Urinalysis: _____________

 

Physical Exam:

General Appearance: ____________________________________

Skin: ____________________________________________________

Head: ___________________________________________________

Neck: ___________________________________________________

Eyes: ____________________________________________________

                Vision Test: Both ______ Right ______ Left ______

 

Ears: _____________________________________________________

                Hearing Test:  pass     fail

 

Nose/Mouth/Throat: _______________________________________

Chest: ____________________________________________________

Abdomen: ________________________________________________

Genitalia: _________________________________________________

Back and Extremities: ____________________________________

Neurological Exam: _________________________________________

 

Chronic conditions and treatment: _________________________

___________________________________________________________

___________________________________________________________

Should physical activity be restricted? yes____ no_____

If yes, specify degree_______________________________________

Other restrictions __________________________________________

Preferential Seating_________________________________________

 

Signature: _______________________________________________

Date: ___________          Date of Examination: ________________