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Doctors use physical exam forms to document a patient's health history and any problems or symptoms they notice during the exam. There are many different types of physical exam forms, but all have the same purpose: to help doctors track a patient's health and diagnose any potential problems. Recently, a new fillable physical exam form was created that makes it easier for doctors to record information. This form can be filled out on a computer or tablet, which speeds up the documentation process. Additionally, it includes checkboxes so doctors can quickly identify any symptoms or problems. Overall, this is an excellent tool for doctor's offices everywhere.

If you'd like to find out some specific details in relation to the file you'll use, here is the data you should study before filling out the fillable physical exam form.

QuestionAnswer
Form NameFillable Physical Exam Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesVaricella, BMI, Meningococcal, Pertussis

Form Preview Example

H511.336 (Rev. 9/2012) Page 1 of 4: STUDENT HISTORY

 

Private or School

 

PHYSICAL EXAMINATION

Bureau of Community Health Systems

OF SCHOOL AGE STUDENT

Division of School Health

 

Student’s name __________________________________________________________________________

Date of birth ________________________

Age at time of exam___________

PARENT / GUARDIAN / STUDENT:

Complete page one of this form before student’s exam. Take completed form to

appointment.

Today’s date___________________________

Gender: Male Female

Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking:

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Does the student have any allergies? No Yes (If yes, list specific allergy and reaction.)

Medicines

Pollens

Food

Stinging Insects

 

 

 

 

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.

 

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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Signature of parent / guardian / emancipated student_____________________________________________________ Date_______________

Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

Page 2 of 4: PHYSICAL EXAM

 

STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ONE

 

 

 

 

Physical exam for grade:

 

 

 

 

 

 

 

 

 

NORMAL

*ABNORMAL

DEFER

 

 

 

 

K/1 6 11

Other

*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height:

(

 

) inches

 

 

 

 

 

 

Weight:

(

 

) pounds

 

 

 

 

 

 

BMI:

(

 

)

 

 

 

 

 

 

 

BMI-for-Age Percentile: (

 

) %

 

 

 

 

 

 

Pulse:

(

 

)

 

 

 

 

 

 

 

Blood Pressure:

(

/

)

 

 

 

 

 

 

Hair/Scalp

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

 

 

Eyes/Vision

Corrected

 

 

 

 

 

 

Ears/Hearing

 

 

 

 

 

 

 

 

 

Nose and Throat

 

 

 

 

 

 

 

 

 

Teeth and Gingiva

 

 

 

 

 

 

 

 

Lymph Glands

 

 

 

 

 

 

 

 

 

Heart

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

 

 

 

 

 

 

 

Genitourinary

 

 

 

 

 

 

 

 

 

Neuromuscular System

 

 

 

 

 

 

 

 

Extremities

 

 

 

 

 

 

 

 

 

Spine (Scoliosis)

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUBERCULIN TEST

DATE APPLIED

 

DATE READ

 

 

 

 

 

 

RESULT/FOLLOW-UP

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

(Additional space on page 4)

Parent/guardian present during exam: Yes

No

 

 

Physical exam performed at: Personal Health Care Provider’s Office

School

Date of exam______________20______

Print name of examiner _______________________________________________________________________________________________________

Print examiner’s office address___________________________________________________________________ Phone_______________________

Signature of examiner______________________________________________________________________ MD DO PAC CRNP

Page 3 of 4: IMMUNIZATION HISTORY

HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.

IMMUNIZATION EXEMPTION(S):

Medical

Date Issued:___________

Reason: __________________________________________________

Date Rescinded:___________

Medical

Date Issued:___________

Reason: __________________________________________________

Date Rescinded:___________

Medical

Date Issued:___________

Reason: __________________________________________________

Date Rescinded:___________

NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VACCINE

 

 

 

DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Diphtheria/Tetanus/Pertussis (child)

 

 

 

 

 

 

 

 

 

 

Type: DTaP, DTP or DT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diphtheria/Tetanus/Pertussis

 

1

 

2

3

4

5

 

 

 

 

 

 

 

 

 

 

 

 

(adolescent/adult)

 

 

 

 

 

 

 

 

 

 

 

Type: Tdap or Td

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

 

Type: OPV or IPV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Hepatitis B

(HepB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Measles/Mumps/Rubella (MMR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mumps disease diagnosed by physician

 

 

Date:__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Varicella:

Vaccine

Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Serology: (Identify Antigen/Date/POS or NEG)

 

 

 

 

 

 

 

 

 

 

i.e. Hep B, Measles, Rubella, Varicella

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Meningococcal Conjugate Vaccine (MCV4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Human Papilloma Virus (HPV)

 

 

 

 

 

 

 

 

 

 

Type: HPV2 or HPV4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

 

 

6

 

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type: TIV (injected)

 

 

 

 

 

 

 

 

 

 

 

LAIV (nasal)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

 

12

13

14

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Haemophilus Influenzae Type b (Hib)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Pneumococcal Conjugate Vaccine (PCV)

 

 

 

 

 

 

 

 

 

 

Type: 7 or 13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Hepatitis A (HepA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

4

5

 

 

Rotavirus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Vaccines: (Type and Date)

Page 4 of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER)