Health Examination Form

Health Examination Form
INFORMATION
Name
First NameLast Name
DOB
MonthDayYear
Date
Sex
HEALTH HISTORY
Allergies
Please indicate the type.
Asthma
Please indicate the type.
Seizures
Please indicate the type.
Date of last seizure:
MonthDayYear
Date
Diabetes
Please indicate the type.
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):
Hyperlipidemia:
Hypertension:
PHYSICAL EXAMINATION/ASSESSMENT
Enter the information below.
Rows Information
Height
Weight
BP
Pulse
Respirations
Enter the information below.
Rows 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.
SCREENINGS
Vision
Rows Not Done Right Left
Distance Acuity 7
Near Vision Acuity 8
Color/ Perception Screening
Hearing
Rows Not Done Right Left
Pure Tone Screening 9
Scoliosis
Rows Negative Positive Not Done
Scoliosis 10 11 12
IMMUNIZATIONS
Please choose one.
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.Format: (000) 000-0000.
Should be Empty:

Rows	Not Done	Right	Left
Pure Tone Screening	9

Rows	Negative	Positive	Not Done
Scoliosis	10	11	12

Select theme:

INFORMATION