Career Tech Guam: Physical Exam Form

Physical Exam Form
Pt. 1: This portion is to be completed by the student’s parent/guardian.
Student General Information
Name

First NameLast Name
Gender

MaleFemaleOther
Date of Birth

MonthDayYear
Date
Grade Level SY22-23
Parent/Guardian #1 Name

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Name

First NameLast Name
Email
example@example.com
Parent/Guardian #2 Phone
Please enter a valid phone number.
Student Health History

(Please indicate age and/or year on past and current medical conditions.)
AnemiaHeart DiseaseAsthmaHernaChickenpoxMumpsConvulsions/ SeizureRheumatic FeverDiabetesSkin DisorderMeaslesTuberculosisHay FeverVisionHearingOther
NOTE: You must also submit a copy of the student’s immunization records to complete Registration Requirement #2.

Pt. 2: Please PRINT this portion of the form as it is to be completed by a health professional.

Student Name: ____________________________

Student DOB: __________________

Student Medical Information

Height: ________ Weight: ________ Blood pressure: ________

Vision: (R) ______ (L) ______ Hearing: (R) ______ (L) ______

Any head injuries/dizziness? ___ No Yes, explain: __________________________
Any fractures? ___ No Yes, date: ____________________________
Any allergies? ___ No Yes, list: _____________________________
Any lung disease? ___ No Yes ___
Any heart disease? ___ No Yes ___
Previous hospitalization? ___ No Yes, date: ____________________________
Currently taking medication? ___ No Yes, name of medication(s): ______________ _____________________________________________________________________
Handicapping conditions? (Please explain and specify.) _________________________ _____________________________________________________________________
Student Physical Examination

Complete each item below.	Yes	No	Describe findings if abnormal, or reason for not examining. General appearance
General appearance
Skin
Hair
Nails
Eyes: External (Pupil/Cornea)
Optic Fundus
Auditory Acuity
Muscle Balance
Ears: External
Auditory Acuity
Tympanic Membrane
Nose
Mouth
Pharynx
Larynx
Speech
Teeth/Gums
Neck/Lymph/Larynx
Cardiovascular
Respiratory
Gastrointestinal
Genital-urinary
Muscular-skeletal
Scoliosis Screening
Neurological
Impressions
Nutritional Status
Behavior during Examination
Other

Physical examination remarks or recommendations: _________________________________ ___________________________________________________________________________

_______________________ _________________________ __________

Name of Examiner/Physician Signature of Examiner/Physician Date

Thank you for completing Registration Requirement #2. If your child is in 10th, 11th, or 12th grade, then please proceed to Registration Requirement #3, the Transcript Upload.
Should be Empty:

Physical Exam Form

Student General Information

Student Health History

Student Physical Examination