ST. ANN SCHOOL PHYSICAL FORM

2008-09

A physical examination is required of all incoming 4th and 8th grade students by St. Ann School.

Please take the form below with you, and upon completion of the examination, return the form to school no later than September 19th. If a physical has been obtained before the receipt of this form, please attach proof from your physician that indeed a physical was performed. Usually the doctor’s office will fill out the form if a physical was done within a certain amount of time like 3 months. If there are any questions regarding the physical, the school nurse will contact the parent.

NAME ___________________________________ GRADE _________

SCHOOL ________________________________

A complete physical examination on the above named child was performed this date:

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HEIGHT ____________ WEIGHT ____________ BLOOD PRESSURE ___________

GENERAL APPEARANCE __________________________________

EVIDENCE OF CHRONIC DISEASE (DESCRIBE IF PRESENT)

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PHYSICAL LIMITATIONS (ENUMERATE) ________________________________________

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DATE PHYSICIAN’S SIGNATURE