Please attach a copy of child's Immunization Record to this form

Ohio Department of Health   • School and Adolescent  Health
Physical Examination

Student’s name	Sex
a Male	a Female	Date of birth
/	/	
Height	Weight	BMI percentile	BP	

Screening Tests
Vision	Hearing 	Postural

Date performed
/	/	Date performed
/	/	Date performed
/	/	
Distance Acuity	a R	a L Muscle Balance	a Pass	a Fail Stereopsis	a Pass	a Fail Color 	a Pass	a Fail Child wears glasses?	a Yes 	a No Tested with glasses?	a Yes 	a No Referral made?	a Yes 	a No	
Pure Tone
Right ear	a Pass    a Fail
Left ear	a Pass    a Fail
Child wears hearing aid?	a Yes 	a No
Child under the care
of a hearing specialist	a Yes 	a No
Referral made?	a Yes 	a No	a No abnormality noted
a Screening not done a Referral made Comments

Speech/Language                                                                        Lead Poisoning
Speech assessment completed                       a Yes      a No          a Date                                  Child has no discernible speech problem      a Yes      a No          a Date                                  Speech evaluation recommended                  a Yes      a No         Tuberculin  Test

Type	a C   a V	Results 	µg/dL Type	a C   a V	Results 	µg/dL

Child has possible problem with  	

Date  	

Type  	

Results 	

Health  History (Serious or chronic illnesses/injuries/surgeries)

Physical Examination Date of most recent examination 	/	/
a Essentially normal 	a Abnormalities as follows

Is this child able to participate fully in:		
Classroom and academic activities
Competition athletics	a Yes 	a No
a Yes 	a No	Physical education classes
Contact and collision sports	a Yes 	a No
a Yes 	a No	
If limitations are advised, please specify				

Does this child have any physical, developmental or behavioral issues that may affect his/her educational process?

HealthCare Provider’s signature	Print name	Phone
( 	)	
Address	Date
/	/	
City	State	ZIP	

HEA 4242  8/06