School Physical Form

Report 0 Downloads 20 Views

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above ... Laboratory confirmation (check one) OMeasles OMumps.

Recommend Documents
Health care provider (MD, APN, PA, school health professional, health official) verifying above immunization history must sign below. Signature Title - - Date. Signature Title Date. (If adding dates to the above immunization history section, put your

Nose and Throat. Teeth and Gingiva. Lymph Glands. Heart. Lungs. Abdomen. Genitourinary. Neuromuscular System. Extremities. Spine (Scoliosis). Other. TUBERCULIN TEST. DATE APPLIED. DATE READ. RESULT/FOLLOW-UP. MEDICAL CONDITIONS OR CHRONIC DISEASES WH

Bee Sting Ailergy areas casca Headaches - -. Asthma see seaso Head injury Concussion to pass. Anemia - Heart Problem/Murrur/Chest Pain - --. Athritis auao ...

Has anyone in your family died of heart problems or a sudden death before age 50? Does anyone in your family have a heart condition? Has a doctor ever ...

Title. Date. ALTERNATIVE PROOF OF IMMUNITY. 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, .... SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for ar

Snuff of dip? • Be you drinkaicchè ºf use any other drugs? • Have you ever taken anabolic steroids of used any other performance supplement? • Haweyati ever ...

Revised March 2013. VIRGINIA ... also all other standards set by your League, district and school. .... practice in the United States will be accepted ... cheerleading, cross country, field hockey, football, golf, gymnastics, lacrosse, soccer, softba

You may use the Physicians Permit For Athletic Participation Form below or submit the clearance form you received from the physician (physician's form must ...

Physical examination must be completed by a medical doctor, doctor of osteopathy, certified nurse practitioner, or certified physician assistant. Name: ...

26, Do you cough, wheeze, or have trouble breathing during or. Havey had surgery? . after activity? 27, Do you have asthma? 5. Are you currently taking any ...