Mercersburg Academy Student Health Form

Report of Physical Examination

_____________________________ ______________________ _________________

Students Last Name

First Name

BP: _______ /_______

Pulse: _______ Resp: _______
Vision Exam
With Corrective lenses
Without Corrective lenses
Right: 20/ _______ Left: 20/ _______

______________

Middle Name

Height (in inches): _________

Weight (in pounds): ________

Food, Medication or Other

Allergies

Hearing Test:
Method: __________________
Right: ____________________
Left: _____________________

_____________________
_____________________
_____________________
Does the patient require
an EpiPen?___________

Date of Birth

Other Test Results

(as indicated)

_____________________
_____________________
_____________________
_____________________

Immunization Report
New Students: Please provide proof of vaccination (see attached vaccine requirements).

Returning students: Update required vaccinations as needed. _______________________________________________

Please note: All students must have received a tetanus booster with pertussis (Tdap) within 5 years.

Tuberculosis (Tb) Screening: Based on recommendations by the AAP Red Book Report of the Comm. On Infect. Diseases.
A PPD skin test for tuberculosis is required for students who answer YES to ANY of the fol- Has the student had BCG?
lowing questions: (Please answer all questions.)
Yes_________ No__________

Has a family member or close contact had tuberculosis? ..Yes___ No___

Has a family member had a positive tuberculin skin test? ....Yes___ No___
Are you from a high risk country (a country other than the United States, Canada, Australia, New Zealand or Western and Northern European countries)? .Yes___ No___
Have you traveled to a high risk country for more than 1 week (including school trips)?
......Yes___ No___

NOTE:

History of BCG vaccination

does not preclude testing a
member of a high-risk group.

Date of test (if indicated)__________________ Results __________________

Chest x-ray is required if TB skin test is positive.
Date of x-ray______________ Results ______________ Treatment completed? Yes___ No___

Physical Exam: Describe any abnormalities (marked as YES).

Any abnormalities?
1. Eyes
2. Head, Ears, Nose & Throat
3. Dental
4. Respiratory

YES

NO

5. Cardiovascular
6.

7. Hernia
Genitourinary

9.

Musculoskeletal

10. Metabolic/Endocrine
11. Neuropsychiatric
12. Skin & Lymphatics

Recommendations/Restrictions
General:
Activities:

Gastrointestinal

8.

Any ongoing, chronic, or recurrent medical conditions? Specify. Attach any

pertinent consult notes.

Nutritional:

Is the student cleared for all physical activity, including

sports?
Yes___ No___

List all prescription medicines ordered for student: (Please include name, strength, & administration instructions)
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Health Care Providers Signature: __________________________________________ Date of Examination: ______________
Name, Address, and Telephone (please print): ___________________________________________________________________