"Medical Report Template - Waukee Community School District"

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WAUKEE   C OMMUNITY   S CHOOL   D ISTRICT    
MEDICAL   R EPORT  
 
Student   N ame____________________________________________________         G ender     M       F           B irthdate   _ ________________  
Parents/GuardianName__________________________________________________________________________________________  
Address_____________________________________________________     C ity____________________________     S tate______________    
School   o f   A ttendance___________________________________________________     G rade     _ ____________  
 
SIGNIFICANT   H EALTH   H ISTORY  
Yes  
No  
 
Yes  
No  
 
 
 
Asthma  
 
 
Hospitalizations   ( List   B elow)  
 
 
Seizure   D isorder  
 
 
Surgeries   ( List   B elow)  
 
 
Diabetes  
 
 
Allergies      
 
 
Heart   D isorder  
 
 
 
Pleurisy/Pneumonia  
 
 
Rheumatic   F ever  
 
 
Scarlet   F ever  
 
 
Medications  
 
 
Eczema  
 
 
 
Meningitis  
 
 
Chicken   P ox  
 
 
Other   ( List   B elow)  
 
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________  
 
PHYSICAL   E XAMINATION   /   P HYSICIAN   R EPORT                
X   =   N ormal     o r  
 
R
 
ESULTS
Negative  
 
Appearance  
Height     ( Required)  
 
 
Posture  
Weight   ( Required)  
 
 
Nutrition  
Blood   P ressure   ( Required)  
 
 
Development  
Hemoglobin  
 
 
Neurological  
Urinalysis  
 
 
Speech   D efect   Blood   L ead   L evel   ( Required)  
                                      u g/dL         D ate   C ompleted________________  
 
Hair   /   S calp  
Hearing     S creening     ( Required)   Referral       Y es________             N o_________  
 
Nose  
Vision   S creening   ( Required)  
R                   / 20                       L                     / 20                       B oth                     / 20  
Referral       Y es_________           N o   _ _________  
 
Ears  
 
Throat  
Chronic   D isease  
 
 
Thyroid  
Physical   E ducation  
Full   _ _______             L imited   _ _______           N one   _ ________  
 
Lymph   N odes  
Anatomical   R estrictions  
 
 
Heart  
Physician’s   C omments   a nd   R ecommendations  
 
Lungs  
 
Extremities  
 
Abdomen  
 
Skin  
 
Hernia  
 
Back  
 
 
Physicians   S ignature__________________________________________________     D ate   o f   E xam________________  
 
 
 
   
   
 
WAUKEE   C OMMUNITY   S CHOOL   D ISTRICT    
MEDICAL   R EPORT  
 
Student   N ame____________________________________________________         G ender     M       F           B irthdate   _ ________________  
Parents/GuardianName__________________________________________________________________________________________  
Address_____________________________________________________     C ity____________________________     S tate______________    
School   o f   A ttendance___________________________________________________     G rade     _ ____________  
 
SIGNIFICANT   H EALTH   H ISTORY  
Yes  
No  
 
Yes  
No  
 
 
 
Asthma  
 
 
Hospitalizations   ( List   B elow)  
 
 
Seizure   D isorder  
 
 
Surgeries   ( List   B elow)  
 
 
Diabetes  
 
 
Allergies      
 
 
Heart   D isorder  
 
 
 
Pleurisy/Pneumonia  
 
 
Rheumatic   F ever  
 
 
Scarlet   F ever  
 
 
Medications  
 
 
Eczema  
 
 
 
Meningitis  
 
 
Chicken   P ox  
 
 
Other   ( List   B elow)  
 
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________  
 
PHYSICAL   E XAMINATION   /   P HYSICIAN   R EPORT                
X   =   N ormal     o r  
 
R
 
ESULTS
Negative  
 
Appearance  
Height     ( Required)  
 
 
Posture  
Weight   ( Required)  
 
 
Nutrition  
Blood   P ressure   ( Required)  
 
 
Development  
Hemoglobin  
 
 
Neurological  
Urinalysis  
 
 
Speech   D efect   Blood   L ead   L evel   ( Required)  
                                      u g/dL         D ate   C ompleted________________  
 
Hair   /   S calp  
Hearing     S creening     ( Required)   Referral       Y es________             N o_________  
 
Nose  
Vision   S creening   ( Required)  
R                   / 20                       L                     / 20                       B oth                     / 20  
Referral       Y es_________           N o   _ _________  
 
Ears  
 
Throat  
Chronic   D isease  
 
 
Thyroid  
Physical   E ducation  
Full   _ _______             L imited   _ _______           N one   _ ________  
 
Lymph   N odes  
Anatomical   R estrictions  
 
 
Heart  
Physician’s   C omments   a nd   R ecommendations  
 
Lungs  
 
Extremities  
 
Abdomen  
 
Skin  
 
Hernia  
 
Back  
 
 
Physicians   S ignature__________________________________________________     D ate   o f   E xam________________  
 
 
 
 
Health   H istory   F orm   ( to   b e   c ompleted   b y   p arent   o r   g uardian)  
 
 
1. Name of child_________________________ Birth Date_____________
2. Pregnancy, Birth & Development:
a. Were there any difficulties during pregnancy?
Yes
No
If yes, explain:_____________________
b. Was this child carried for full 9 months?
Yes
No
c. Birth weight ________lb. ________oz.
d. Any problems in the hospital during/after birth?
Yes
No
e. Did this child sit alone before 7 mos. of age?
Yes
No
f. Did this child walk alone before 15 mos. of age?
Yes
No
g. Did this child say words by 1&1/2 yrs. of age?
Yes
No
h. Check if the following have occurred with this child:
____sleeping problem ____eating problem
____excessive drooling ____coordination problem
3. Illness and Accidents
Has this child:
a. Had more than 1 ear infection each year?
Yes
No
b. Had more than 2 throat infections each year?
Yes
No
c. Had a hearing problem?
Yes
No
d. Had a vision problem?
Yes
No
e. Had allergy problems, wheezing or asthma?
Yes
No
f. Had frequent colds, sinus infections, hay fever?
Yes
No
g. Received any routine medications?
Yes
No
h. Had serious reactions to any medicine or
injection?
Yes
No
i. Had any problems with bladder or kidneys?
Yes
No
j. Had any problems with bowels or constipation?
Yes
No
k. Ever had convulsions or seizures?
Yes
No
l. Had a weight problem?
Yes
No
m. Had any serious accidents?
Yes
No
n. Had any problems with fainting?
Yes
No
o. Had any problems with headaches?
Yes
No
Please explain any “Yes” answers:
4. Family Health
Do any other family members have any serious health problems? If yes, please
explain:
5. Additional Health Concerns
Please let us know of any additional health concerns or physical limitations
of this child.
Filled   o ut   b y   _ __________________________________Date________________________________  
 
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