Parent's Physical Form
To be completed by Parent/Guardian before physical examination
Student’s Name _____________________________________________Grade __________
Has the student ever had a disease that affects the functioning of the
Eyes?__________Ears?__________Kidneys?__________Lungs?__________
List any surgical operations/procedures with age and/or date:
List any broken bones, sprains, muscle or tendon injuries with age and/or date:
Has the student had any of the following? Please circle yes or no.
Asthma Y N Hepatitis Y N
Allergies Y N Heart Murmur Y N
Blood Disorders Y N Heat Stroke/Exhaustion Y N
Concussion Y N Kidney Disease/injury Y N
Diabetes Y N Seizure Disorder Y N
Fainting/Convulsion Y N Other Serious Illness Y N
Head Injury Y N
Please explain any YES answers to above questions:
___________________________________________________________________________
5. Does the student take any medication now? ________If so, what?_______________________
Does the student wear glasses or contact lenses? ____________________________________
I have answered this medical questionnaire to the best of my knowledge and give permission for my child to have their physical exam done by Dr. Martin Iser at the Hull High School.
Parent/Guardian Signature Date
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