LAUREL SPRINGS SCHOOL DISTRICT

MEDICAL EXAMINATION

 Family Physician is to complete this form

Student’s name:             __________________________                     Date of Exam:  __________

 Address:             ________________________________________________________________

 PHYSICAL FINDINGS

Height:               ________________                             Lungs:              ________________

 Weight:             ________________                             Abdomen:              ________________

 Ears:                  ________________                             Skin:                 ________________

 Nose:                ________________                             Posture:             ________________

 Eyes:                 ________________                             Feet:                 ________________

 Tonsils:             ________________                             Blood Pressure:  ______________

 Teeth:                ________________                             Urinalysis:             ________________

 Glands:             ________________                             Hemoglobin:             ________________

 Heart:                ________________

HEALTH HISTORY

Asthma:             ________________                             Heart Murmur: ___________

 Allergy:             ________________                             TB (self or family:  ____________

 Eczema:             ________________                             Diabetes:              ________________

 Frequent Colds:             __________                             Childhood Illnesses & Hospitalizations:

 Sore Throats:             ________________                             ____________________________

 Ear Infections:             ________________                             ____________________________

 General Comments:     ______________________________________________________________________________

     Code:  X = possible problem                                                  ___________________________________________             

                                                                                                (Signature of Doctor)