SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

School Physical Form

STUDENT NAME ___________________________________________________________

GRADE ___________ AGE _________________ DOB _____________________________

PHYSICAL EXAMINATION:

HEIGHT ____________ WEIGHT ___________ BP __________ PULSE _______________

TETANUS CURRENT? YES / NO

VISION: RIGHT _____/_____ LEFT _____/______ With or without glasses? __________

HEARING: RIGHT: ____________ LEFT: ______________

CHEST X-RAY? YES / NO

IF INDICATED BY PHYSICIAN: Blood: HCT ____ RPR ___ Urine sugar ____ ALB ____

SYSTEM EXAMINATION

EYES

EARS

NOSE

THROAT

NECK

SKIN

HEART

LUNGS/BREAST

ABDOMEN

SPINE

EXTREMITIES

GROIN/GENITALS

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Please list any significant medical history:

I certify that on this date I have examined the above student as indicated by the items checked and recommend him/her as being physically fit and able to participate in the physical activities as checked below.

CLEARED FOR ALL SPORTS/ACTIVITES___________

LIMITED PARTICIPATION____________

NO PARTICIPATION___________

SIGNATURE OF PHYSICIAN: _____________________________ DATE: _____________

PRINT PHYSICIAN NAME: _____________________________PHONE: ______________

PARENT SIGNATURE: ______________________________________________________

STUDENT SIGNATURE: _____________________________________________________

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