Physical Examination Form For StudentsName*UID#GradeSchool Site Birth Date Date Format: MM slash DD slash YYYY SexFatherMotherAddressParent ConsentDate Date Format: MM slash DD slash YYYY Medical history include:rheumatic fever,tuberculosis,epilepsy,allergies,operations,serious illness,congential defects and menstrual distrubances.Has your son/daughter had a concussion? Yes NoIf so,how many?Date of Last Concussion: Date Format: MM slash DD slash YYYY Immunization Recommendations:Physical ExaminationCheckAdditional RemarksNormal,Abnormal,Not ExaminedN ANEGeneral Weight & NutritionAdditional RemarksGeneral ApperanceAdditional RemarksSkin(Acne,Tinea,Dermatitis)Additional RemarksEye(Conjunctivae,Corena,EOM)Additional RemarksEars(Perforations,Deafness)Additional RemarksNose(Allergy,Deformities)Additional RemarksTeeth(Cavities,Gingivitis,Occlusion)Additional RemarksTonsilsAdditional RemarksLymph NodesAdditional RemarksChest(Deformities)Additional RemarksLungsAdditional RemarksHeart(Size,Murmur,Rhythm)Additional RemarksBreastAdditional RemarksAbdomenAdditional RemarksHerniasAdditional RemarksGenitaliaAdditional RemarksBack(Kyphosis,Lordosis,Scoliosis)Additional RemarksSkelton(Limited Motion,Deformities)Additional RemarksFeet(Flat,Pronated,Tinea)Additional RemarksBlood PressureHeightWeightThis student may praticepate in:Competitive Sports Yes NoRegular Physical Education Yes NoLimited P.E Only Yes NoDurationPhysician's SignatureDate Date Format: MM slash DD slash YYYY Type or Print Physician's NameLicense NumberPHYSICALS FROM A CHIROPRACTOR ARE NOT VALID FOR ATHLETIC CLEARANCE