Laurel Springs School

Medical Examination

Student’s Name:  ________________________  Date of birth:  ___________________

Student’s Address:  ________________________________________________________

Physical Findings

Height:         ___________________________    Weight:        _____________________

B.P.:            ___________________________    Ears:            _____________________

Nose:           ___________________________    Throat:        _____________________

Tonsils:       ___________________________    Teeth:          _____________________

Glands:        ___________________________    Heart:          _____________________

Lungs:         ___________________________    Abdomen:    _____________________

Skin:            ___________________________    Posture:       _____________________

Feet:            ___________________________    Genitalia:      _____________________

Any serious or chronic illness(es)or allergy treated by physician?  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Remarks:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________                                                        ______________________________

(Date of Exam)                                                      (Signature of Physician)

                                                                             _______________________________

                                                                             (Phone Number of Physician)