2018PHYSICAL EXAMINATION CERTIFICATE
FOR DEPARTMENT USE ONLY
Last Name ______
First Name:______Boys State #______City ______County______
APPLICANT NAME AND MAILING ADDRESS
NAME:______DOB: ______
ADDRESS:______
CITY: ______STATE: ______ZIP: ______
PERSONAL HISTORY: Indicate if the participant has ever had any of the following:
YES NO YES NOYES NO
______Chicken Pox ______Measles______Mumps
______Scarlet Fever ______Frequent Colds______Frequent Sore Throats
______Ear Infection ______Sinusitis______Tonsillitis
______Bronchitis ______Pneumonia______Congenital Heart Problem
______Rheumatic Fever ______Rheumatoid Arthritis______Epilepsy
______Psychiatric Disorder ______Emotional Disorder ______Tuberculosis
______Diabetes ______Anemia______Orthopedic Problems
______Infectious Jaundice/Hepatitis ______Kidney Disease______Mononucleosis
______Chronic Intestinal Problems ______Malignancy______Asthma
______Hay Fever ______Hives______Operations
Injuries:______
Allergies:______
Medications: ______
Special Dietary Requirementsrelated to food allergies, food intolerance or gastrointestinal disease:
______
Health Insurance Carrier:______Group & ID #:______
Personal Physician: ______Telephone (with area code): ______
______
TO BE COMPLETED BY PARENT/GUARDIAN - Person to notify in case of an emergency:
NAME:______PHONE: ______
ADDRESS: ______
NOTE TO PARENT OR GUARDIAN: In order to quickly procure any emergency care that may be necessary for the candidate and to protect the physicians and institutions involved, please complete and sign below:
I, the parent/guardian of ______(NAME OF CANDIDATE), do hereby authorize the nursing and medical staff of Morrisville State College’s Student Health Center to treat my son for illness or injury as appropriate. I also give permission to local emergency room departments and their physicians, to provide appropriate medical, psychiatric, and surgical treatment, including administering anesthetics, as medically indicated in case of emergency.
______ ______Parent ______Guardian (check one) Parent/Guardian Signature Date REV 10/20/2017
NAME ______DOB: ______
ATTENTION PHYSICIAN: Boys’ State, by nature, is strenuous – both physically and emotionally. Therefore, ability to cope adequately with these conditions should be seriously considered when completing this form.
Dates of: Td or Tdap Booster______MMR: ______
PHYSICAL EXAMINATION
Height:_____ Weight:_____ Blood Pressure:______Pulse:_____ Hearing:______
Visual Acuity: ______R______L______
CLINICAL EXAMINATION
(Check each item in proper column. Enter NE if not evaluated.)
NORMALABNORMALCOMMENTS
1. Eyes______
2. Ears, Nose, Throat______
3. Hearing______
4. Mouth/Teeth______
5. Cardiovascular______
6. Chest/Lungs______
7. Abdomen______
8. Genitourinary______
9. Musculoskeletal______
10. Metabolic______
11. Neurological______
12. Skin______
13. Lymphatic______
14. Psychiatric______
Does this boy have any physical limitations or restrictions which would hinder his participation in Boys’ State?
Yes____ No ____ (If yes, please explain. Attach additional sheets if necessary)
______
Physician’s Signature: ______Date: ______
Address:______
Phone: ______
REV 10/20/2017