Name:  __________________________________________

MEDICAL EXAMINATION REPORT - BY PHYSICIAN

1.  Age _____    2.  Height ______    3.  Weight ______  4.  Blood Pressure ____________

5.  General appearance, nutritional state, vitality: __________________________________

_______________________________________________________________________

6.  Skin (pallor, condition, pilonidal sinus) _______________________________________

7.  Head _______________________________________________________________

8.  Eyes _______________________________________________________________

9.  Ears _______________________________________________________________

10. Mouth (teeth and muc. memb.) __________________________________________

11. Nose _____________________________________________________________

12. Throat ____________________________________________________________

13. Neck (lymph nodes and thyroid) _________________________________________

14. Chest _____________________________________________________________

15. Heart ______________________________________________________________

16. Lungs _____________________________________________________________

17. Abdomen (hernia) ___________________________________________________

18.  Genitalia _________________________________________________________

19.  Posture and extremities (including skeletal abnormalities) ______________________
____________________________________________________________________

20. Neurological ________________________________________________________

21. Comments on emotional behavior __________________________________________

22.  Speech difficulty ______________________________________________________

23.  Other ______________________________________________________________

24. Tuberculin test:  Date ____________ Result _________ Other lab reports __________

25.  Is this child capable of carrying a full program of school work including gymnastics and athletics?  Yes _______   No _______

26.  Restrictions and/or recommendations _________________________________________
_________________________________________________________________________

Date ________________    Physician's Signature _______________________ 

Phone __________    Physician's Address ___________________________________