Puget Sound Adventist Academy School

Puget Sound Adventist Academy School

5320 108th Ave NE Kirkland, WA 98033 (425) 822-7554 Fax: (425) 828-0856 www.ksdaschool.org

Medical Examination of Student by Physician

Name of student______Age____Date of examination___/___/___

TO THE EXAMINING PHYSICIAN: This report will be held in confidence and used only to aid in adjusting the student’s educational program to best meet his or her needs. Please record on this form the positive findings of your examination, and especially your recommendations to the school as to how the student’s physical condition should affect his or her participation in school-related physical activities and the educational program. Thank you.

Please indicate below, by a check in the column on the left, any positive findings on medical examination and describe to the right.

___ Allergies ______

___ Asthma ______

___ Bee sting allergy ______

___ Chronic earaches ______

___ Diabetes (insulin dependent, ______

non-insulin dependent)

____ Frequent colds (#/year) ______

___ Head injury (previous concussion, etc) ______

___ Headaches ______

___ Hearing loss ______

___ Nosebleeds ______

___ Neurological problems ______

___ Surgeries ______

___ Orthopedic condition ______

(fractures, sprains, dislocations)

___ Physical handicap ______

___ Scoliosis ______

___ Seizure disorder ______

___ Visual problems ______

___ Other illness (hepatitis, kidney/bladder,

blood disorder, mononucleosis)

Vision: R______L______Hearing: R______L______

Date of last dental visit (twice yearly recommended): ______

Specify medical recommendations to school for academic and activity program, if necessary:
Examining physician______Address______