Maranatha Seventh-day Adventist Christian School
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Physical Exam and Health History
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WISCONSIN CONFERENCE OF SEVENTH-DAY ADVENTISTS
ELEMENTARY SCHOOLS
 
PHYSICAL EXAMINATION & HEALTH HISTORY FORM
 
The following information is requested so the school and parent can work together to meet the physical, intellectual, and emotional needs of the child.
 
Child’s Health History      Date: ______________    Grade K 1 2 3 4 5 6 7 8 9 10                   Date of Birth ____________
 
Child’s Name: ____________________________________________________________________________________________________
                                                Last                                                        First                                                                                        Middle
 
Address: ________________________________________________________________________________________________________
                                Street                                                                      City                                                        State                                       Zip
 
Child’s Physician: _____________________________________________      Physician’s Phone ________________________________
 
Physician’s Address: ______________________________________________________________________________________________
                                                Street                                                      City                                                        State                                       Zip

PAST ILLNESS – please check (x) those which your child has had below)
                Measles __            Diabetes __           Chicken Pox __   Heart Disease __                                 Mumps __            Epilepsy __           Polio __
                Small Pox __        Scarlet Fever __   Frequent colds (No. Per year) ___                    Hay Fever or Asthma __
1. Please specify any other serious illness, operation or injury, and age when occurred: __________________________________________
 
________________________________________________________________________________________________________________
 
2. Has your child been exposed to tuberculosis? Yes __ No __   If so, Year ___________

GENERAL HEALTH –
1. Does your child have any condition or illness that you feel the school should know about? Yes __ No __ If yes, please explain: ______
 
________________________________________________________________________________________________________________
2. Does your child wear glasses or corrective lenses? Yes __ No __ If yes, last exam date: ___________________
3. Does your child have hearing difficulties? Yes __ No __ If yes, last exam date: _________________
4. Does your child have any allergies? Yes __ No __ If yes, what are they and how are they treated? ______________________________
 
5. Is there any special medical need you’d like the school to assist your child with during the school year? If yes, please specify: ________
 
________________________________________________________________________________________________________________
 
Parent/Guardian Signature: ____________________________________
 
EXAMINATION RECORD TO BE FILLED OUT BY THE PHYSICIAN:
General appearance: __________   General nutrition: __________   Blood pressure: __________   Hearing (Audiometric): _____________
Tonsils & adenoids: __________   Other lab exam: _____________   Height: _________   Weight: _________   Posture: ______________
Feet: ________   Skin: ________   Abdomen: __________   Heart: _________   Genitals: ________   Hernia: ________   Pulse: _________
Vision (right eye): _________   Vision (left eye): _________   Thyroid: _______   Other glands: __________   Reflexes: ___________
Lungs: ____________   Emotional status: __________________________________   General Condition: __________________________
 
Is the student capable of carrying a full program of school works, including Physical Education? Yes __ No __   If no, please give reason and state limitations: _______________________________________________________________________________________________
 
________________________________________________________________________________________________________________
Is student subject to conditions that may cause classroom emergencies, such as epilepsy, diabetes, fainting, allergies, asthma, other? 
Yes __ No __ If yes, explain ________________________________________________________________________________________
 
________________________________________________________________________________________________________________
Is the student’s immunization test up to date? Yes __ No __
 
(Child’s name) ____________________________ has been examined by me and found free of disease and is physically and mentally able to participate in group activities.
Physician’s Signature: __________________________________     Date: ________________________________
 
Prepared by the WCSDA ED DEPT 1997                                C:\Documents and Settings\Owner\My Documents\Red Book\Physical Exam & Health History Form.doc