Physical Examination Format Pdf Form PDF Details

The Physical Examination Format PDF form serves as a comprehensive document designed for assessing the health status of students at Collingswood Schools. This crucial form captures a wide array of health-related information that includes personal details such as name, age, date of birth, gender, contact information, school grade, and the examining physician's contact details. The heart of the form lies in its detailed assessment sections that meticulously record the student's physical metrics like height, weight, blood pressure, and pulse, alongside visual and auditory health indicators. Key observations from a physical examination covering various physiological areas such as head, neck, cardiovascular system, lungs, skin, abdomen, and neurological health are systematically recorded. The form extends into a more specialized review, noting recent immunizations, current medications, and any remarkable health history that might impact the student's educational experience. Additionally, it offers an essential segment on clearance for physical education, specifying the conditions under which a student may or may not participate in physical activities based on their health evaluation. Revised in February 2008, this intricately designed form ensures a thorough medical assessment, providing a reliable basis for safeguarding student health and ensuring a conducive learning environment.

QuestionAnswer
Form NamePhysical Examination Format Pdf Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesPneumococcal, INH, sample physical assessment pdf, 2008

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAMINATION FOR COLLINGSWOOD SCHOOLS

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age:

 

DOB:

 

 

 

 

 

 

 

 

 

Gender:

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip

 

 

 

Home Phone:

 

 

 

 

 

 

 

 

 

 

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grade:

 

 

 

 

Physician:

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

Physician’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN OR PROVIDER INFORMATION – PLEASE COMPLETE BOTH SIDES

 

 

 

Exam Date:

 

 

 

 

 

Height:

 

Weight:

 

 

 

Blood Pressure:

 

 

 

/

 

 

 

 

Pulse:

 

 

bpm.

Vision: R 20/

L 20/

 

Corrected: Y / N

Contacts: Y

/ N Glasses: Y /

N

Hearing:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal

 

 

 

Abnormal Findings

 

 

 

 

 

 

 

 

Comments

 

 

 

Head/Neck

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes/Sclera/Pupils

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ears

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose/Mouth/Throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Murmurs/Rhythms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lungs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auscultation/Percussion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chest Contour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment (inc. liver, spleen)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tanner Stage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Testes/Onset of Menses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes/Possible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hernia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neck/Back/Spine:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Range of Motion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scoliosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Upper Extremities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lower Extremities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurological:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Balance & Coordination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Romberg

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heel Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tandem Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose Touch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toe Walk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Most recent immunizations/Dates:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications currently in use:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Observations/Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 2/2008

 

 

 

 

 

 

 

 

Continued on back of page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HISTORY: Please check all areas where diseases or alterations have occurred and explain below:

 

Allergies/Anaphylaxis

 

Eczema/Skin

 

 

Hospitalizations/Surgery

 

Asthma/Respiratory

 

Endocrine

 

 

Musculoskeletal

 

Cardiovascular/Murmur

 

Gastrointestinal

 

 

Neurological/Seizures

 

Childhood diseases

 

Genitourinary

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation/comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLEARANCE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

Student may participate in physical education: Yes:

 

 

No:

 

 

Date:

 

 

B.

Cleared after completing evaluation for:

 

 

 

 

 

 

 

 

C.

NOT CLEARED FOR: Collision:

 

 

 

Contact:

 

 

 

Non-Contact:

 

 

 

 

 

 

Strenuous:

 

 

 

Moderate:

 

 

 

Non-Strenuous:

 

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommendations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only this certificate is to be used to certify that a child has met the immunization requirement for attending school. Include immunizations given on this date. ALL DATES MUST INCLUDE DAY, MONTH AND YEAR.

VACCINE

TOTAL #

DATE

 

DATE

 

DATE

 

DATE

 

DATE

 

DOSES

 

 

 

 

 

 

 

 

 

 

DPT/DTaP

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Pediatric DT*

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

OPV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

IPV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

MMR

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Measles

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Mumps

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Rubella

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

HIB or Prohibit

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Varicella

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal (PCV7)

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Meningococcal

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

RSV

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

* Requires a physician’s written medical contraindication to further pertussis vaccine when given to children under age 7.

TUBERCULOSIS TESTING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mantoux tests:

Date:

 

Result:

 

 

 

 

Date:

 

 

 

Result:

 

Chest x-ray:

Date:

 

Result:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INH Therapy:

Date started:

 

 

 

 

 

Dosage:

 

 

 

 

How long:

 

EXAMINED BY: Physician’s/Provider’s Stamp:

Family Physician/Provider:

 

 

 

 

School Physician:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___ MD ___ DO ___ NP ___PA

Physician’s/Provider’s Signature

Date

Revised 2/2008

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When it comes to blanks of this particular document, here's what you should know:

1. When completing the foot physical exam, ensure to complete all necessary blanks within its relevant part. This will help hasten the work, allowing for your details to be handled promptly and accurately.

2008 conclusion process outlined (step 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Exam Date Vision R HeadNeck, and YesPossible with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part number 2 for filling out 2008

3. In this part, take a look at Exam Date Vision R HeadNeck, Revised, and Continued on back of page. Every one of these have to be completed with greatest focus on detail.

Continued on back of page, Exam Date Vision R  HeadNeck, and Revised of 2008

4. To move forward, the next stage involves completing several blank fields. These include HISTORY Please check all areas, AllergiesAnaphylaxis, EczemaSkin Endocrine, HospitalizationsSurgery, A Student may participate in, Contact Moderate, NonContact NonStrenuous, Only this certificate is to be, VACCINE, TOTAL DOSES, DATE, DATE, DATE, DATE, and DATE, which you'll find crucial to going forward with this particular PDF.

2008 conclusion process explained (step 4)

5. And finally, this final part is what you need to complete prior to using the document. The blanks here include the following: OPV, IPV, MMR, Measles, Mumps, Rubella, Hepatitis B, HIB or Prohibit, Varicella, Pneumococcal PCV, Meningococcal, RSV, and Influenza.

Step # 5 for filling out 2008

Be really careful when filling out Influenza and Pneumococcal PCV, since this is where a lot of people make some mistakes.

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