REPORT OF PHYSICAL EXAMINATION PORTSMOUTH SCHOOL DEPARTMENT

A health examination by a physician is required for all students entering the school system, as well as any student entering grade 4, 7, or 10. The information provided is used in your child’s school health guidance. Please return this form to your child's school nurse.

TO BE COMPLETED BY PARENT:

Child's Name _______________________________ Date of Birth ________________ Sex ___________

Address ___________________________________ School _____________________Grade __________

Doctor's Name and Address _____________________________________________________________________

 

THIS SECTION TO BE COMPLETED BY THE PHYSICIAN:

Height _____________ Weight _________________ Lungs _____________________________________

Nutrition ___________________________________ Abdomen: Hernia ___________ Other __________

Ears ______________________________________ Liver _________________ Spleen ______________

Eyes __________________ Glasses (?) __________ Orthopedic _________________________________

Nose ______________________________________ Scoliosis ___________________________________

Tonsils ____________________________________ Nervous System _____________________________

Glands: Cervical _________ Thyroid ____________ Skin ______________________________________

Heart: Functional _________ Organic ___________ Speech ____________________________________

Teeth and Gingiva ___________________________ Blood Pressure ______________________________

Femoral Pulse ______________________________ Medication _________________________________

Allergies __________________________________ Food Allergies ______________________________

Illnesses, Injuries, Operations (note dates) __________________________________________________________

____________________________________________________________________________________________

Family History of Diabetes: No ____ Yes ____ (relationship) __________________________________________

Able to participate in all Physical Education and Sports: No ____ Yes ____ Comment ______________________

____________________________________________________________________________________________

Physical or emotional conditions of which the school should be aware: ___________________________________

____________________________________________________________________________________________

ENTER MONTH, DAY AND YEAR FOR EACH DOSE
 

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Diphtheria

            

Measles

      

Pertussis

            

Mumps

     

Tetanus

            

Rubella

      

Polio

            

PPD: ___ Neg. ___ Pos.

  

HIB

            

Lead Screening: Date: ____________

  

Hepatitis

            

Results: __________

  

Varicella

or date of natural immunity

 

_____________________________________________ ________________________

Signature of Physician Date

ADM-07-01