PHYSICIAN’S REPORT OF HEALTH EVALUATION

To the examining physician:  Please review the student’s history and complete the physician’s report and immunization record.

STUDENT’S NAME: _______________________________ DOB: __________________

B/P ______/_______  Pulse _________reg/irr    Height _______  Weight __________

Vision R20/______ L20/______ Corrected R20/______  L20/______  

Hearing R ______/______            L_____/_____

                          Normal         Abnormal    Explain:

General Health – please attach a separate sheet for the following questions if necessary:

Have you any general comments regarding the care of this client? __________________________________________

Is the student under treatment for any medical/emotional conditions?  ______________________________________

Does the student have any significant medical history of which we should be aware?  ___________________________

Is student’s health satisfactory for full participation in varsity, club or intramural sports? _________________________

Please furnish as much information as possible so that we may help you care for your patient while they are on campus.  Also please note that the Health Center is closed during the summer and over school breaks.

Menstruation age of onset: ______;  lasts _____ days; regular   every ______ days;  irregular

Pain:  never/sometimes/always   Usual treatment of pain ___________________________

Last PAP test:  date _____/_____/_____  normal abnormal N/A

Date of physical exam: _____/_____/_____

____________________________________________          ______________________________________

Physician’s Name (printed)                                                           Physician’s signature

___________________________________________           __________________________

Address                                                                                      City / State / Zip

(_____) _______________________                                      ( ______) _________________

Phone                                                                                           Fax