Health Examination Form

Health Examination Form
INFORMATION
Name*
First NameLast Name
DOB*
MonthDayYear
Date
Sex*
MaleFemale
HEALTH HISTORY
Allergies*
YesNo
Please indicate the type.
Medication/Treatment Order AttachedAnaphylaxis Care Plan Attached
Asthma*
YesNo
Please indicate the type.
IntermittentPersistentMedication/Treatment Order AttachedAsthma Care Plan Attached
Seizures*
YesNo
Please indicate the type.
Medication/Treatment Order AttachedSeizure Care Plan Attached
Date of last seizure: *
MonthDayYear
Date
Diabetes*
YesNo
Please indicate the type.
12Medication/Treatment Order AttachedDiabetes Medical Mgmt. Plan Attached
Consider screening for T2DM if your BMI is greater than 85% and you have two or more risk factors: family history of T2DM, ethnicity, sx insulin resistance, mother's gestational Hx, and/or pre-diabetes.
BMI(kg/m2): *
Percentile (Weight Status Category):*
< 5th5th-49th50th-84th95th-98th95th-98th99th >
Hyperlipidemia:*
YesNoNot done
Hypertension:*
YesNoNot done
PHYSICAL EXAMINATION/ASSESSMENT
Enter the information below.*
Information
Height
Weight
BP
Pulse
Respirations
Enter the information below.*
Positive Negative
Laboratory Testing 1 2
TB-PRN 3 4
Sickle Cell Screen PRN
5 6
Please indicate the other pertinent medical concerns. (e.g. concussion, mental health, one functioning organ)
System review and abnormal findings listed near.*
HEENTDentalNeckLungsGenitourinaryNeurologicalMusculoskeletalLymph nodesAbdomenExtremitiesCardiovascularBack/SpineSkinSocial/ Emotional
SCREENINGS
Vision*
Not Done Right Left
Distance Acuity 7
Near Vision Acuity 8
Color/ Perception Screening*
PassFail
Hearing*
Not Done Right Left
Pure Tone Screening 9
Scoliosis*
Negative Positive Not Done
Scoliosis 10 11 12
IMMUNIZATIONS
Please choose one.*
Record AttachedReported in NYSIIS
HEALTH CARE PROVIDER
Medical Provider Signature:*
Clear
Provider Name:*
First NameLast Name
Provider Address:*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Should be Empty:

	Information
Height
Weight
BP
Pulse
Respirations

	Positive	Negative
Laboratory Testing	1	2
TB-PRN	3	4
Sickle Cell Screen PRN	5	6

	Not Done	Right	Left
Distance Acuity	7
Near Vision Acuity	8

Health Examination Form

INFORMATION

HEALTH HISTORY

PHYSICAL EXAMINATION/ASSESSMENT

SCREENINGS

IMMUNIZATIONS

HEALTH CARE PROVIDER