Fillable Physical Exam Form – Fill Out and Use

Private or School

PHYSICAL EXAMINATION

Bureau of Community Health Systems

OF SCHOOL AGE STUDENT

Division of School Health

Date of birth ________________________

Age at time of exam___________

GENERAL HEALTH: Has the student…

YES

NO

1. Any ongoing medical conditions? If so, please identify:

 Asthma  Anemia

 Diabetes  Infection

Other_________________________________________________

2. Ever stayed more than one night in the hospital?

3. Ever had surgery?

4. Ever had a seizure?

5. Had a history of being born without or is missing a kidney, an eye, a

testicle (males), spleen, or any other organ?

6. Ever become ill while exercising in the heat?

7. Had frequent muscle cramps when exercising?

HEAD/NECK/SPINE: Has the student…

YES

NO

8. Had headaches with exercise?

9. Ever had a head injury or concussion?

10.Ever had a hit or blow to the head that caused confusion, prolonged

headache, or memory problems?

11. Ever had numbness, tingling, or weakness in his/her arms or legs

after being hit or falling?

12. Ever been unable to move arms or legs after being hit or falling?

13. Noticed or been told he/she has a curved spine or scoliosis?

14. Had any problem with his/her eyes (vision) or had a history of an

eye injury?

15. Been prescribed glasses or contact lenses?

HEART/LUNGS:

Has the student...

YES

NO

16. Ever used an inhaler or taken asthma medicine?

17. Ever had the doctor say he/she has a heart problem? If so, check

all that apply:

 Heart murmur or heart infection

 High blood pressure

 Kawasaki disease

 High cholesterol

 Other:_____________________

18. Been told by the doctor to have a heart test? (For example,

ECG/EKG, echocardiogram)?

19.Had a cough, wheeze, difficulty breathing, shortness of breath or

felt lightheaded DURING or AFTER exercise?

20. Had discomfort, pain, tightness or chest pressure during exercise?

21. Felt his/her heart race or skip beats during exercise?

BONE/JOINT:

Has the student...

YES

NO

22. Had a broken or fractured bone, stress fracture, or dislocated joint?

23. Had an injury to a muscle, ligament, or tendon?

24. Had an injury that required a brace, cast, crutches, or orthotics?

25. Needed an x-ray, MRI, CT scan, injection, or physical therapy

following an injury?

26. Had joints that become painful, swollen, feel warm, or look red?

SKIN:

Has the student…

YES

NO

27. Had any rashes, pressure sores, or other skin problems?

28. Ever had herpes or a MRSA skin infection?

Has the student…

GENITOURINARY:

YES

NO

29. Had groin pain or a painful bulge or hernia in the groin area?

30. Had a history of urinary tract infections or bedwetting?

31. FEMALES ONLY: Had a menstrual period?

 Yes

 No

If yes: At what age was her first menstrual period? ______

How many periods has she had in the last 12 months? ______

Date of last period: ___________

DENTAL:

YES

NO

32. Has the student had any pain or problems with his/her gums or teeth?

33. Name of student’s dentist: ________________________________

Last dental visit:  less than 1 year

 1-2 years  greater than 2 years

SOCIAL/LEARNING:

Has the student…

YES

NO

34.

Been told he/she has a learning disability, intellectual or

developmental disability, cognitive delay, ADD/ADHD, etc.?

35.

Been bullied or experienced bullying behavior?

36.

Experienced major grief, trauma, or other significant life event?

37.

Exhibited significant changes in behavior, social relationships,

grades, eating or sleeping habits; withdrawn from family or friends?

38.

Been worried, sad, upset, or angry much of the time?

39.

Shown a general loss of energy, motivation, interest or enthusiasm?

40.

Had concerns about weight; been trying to gain or lose weight or

received a recommendation to gain or lose weight?

41.

Used (or currently uses) tobacco, alcohol, or drugs?

FAMILY HEALTH:

YES

NO

42.

Is there a family history of the following? If so, check all that apply:

 Anemia/blood disorders

 Inherited disease/syndrome

 Asthma/lung problems

 Kidney problems

 Behavioral health issue

 Seizure disorder

 Diabetes

 Sickle cell trait or disease

 Other________________________________________________

43.

Is there a family history of any of the following heart-related

problems? If so, check all that apply:

  Brugada syndrome

 QT syndrome

 Cardiomyopathy

 Marfan syndrome

 High blood pressure

 Ventricular tachycardia

 High cholesterol

 Other________________

44.

Has any family member had unexplained fainting, unexplained

seizures, or experienced a near drowning?

45.

Has any family member / relative died of heart problems before age

50 or had an unexpected / unexplained sudden death before age

50 (includes drowning, unexplained car accidents, sudden infant

death syndrome)?

QUESTIONS OR CONCERNS

YES

NO

46.

Are there any questions or concerns that the student, parent or

guardian would like to discuss with the health care provider? (If

yes, write them on page 4 of this form.)

TUBERCULIN TEST

DATE APPLIED

DATE READ