Tuxedo Union Free School District
Medical Examination
Name: _____________________________________________ DOB: ______________ Sex: ________
Height: ____________________ Weight: ____________________ Blood Pressure: ________________
Date of Exam: _____________________________________
| Skin: ____________________________ | Lungs: ______________________________ | |
| Eyes: ____________________________ | Hernia: _____________________________ | |
| Ears: ____________________________ | Genito-Urinary: ______________________ | |
| Lymph Nodes: ____________________ | Posture: ____________________________ | |
| Thyroid: _________________________ | Feet: _______________________________ | |
| Nose: ____________________________ | Scoliosis: ___________________________ | |
| Tonsils: __________________________ | Structural: ___________________________ | |
| Teeth: ___________________________ | Nervous System: ____________________ | |
| Gums: ___________________________ | Nutrition:____________________________ | |
| Heart: ____________________________ | Activity Level: _______________________ |
Immunizations
| DPT: | _______ | _______ | _______ | _______ | _______ | _______ | |||||
| POLIO: | _______ | _______ | _______ | _______ | _______ | ||||||
| MMR: | _______ | _______ | |||||||||
| HIB: | _______ | _______ | _______ | _______ | _______ | ||||||
| HEPATITIS: | _______ | _______ | _______ | ||||||||
| VARICELLA: | _______ | ||||||||||
| TUBERCULIN TEST: | _______ |
This child is physically qualified to take part in the regular school program: YES _______ NO _______
Special Instructions regarding this pupil's health:
____________________________________________________________________________________
____________________________________________________________________________________
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Examiner's Signature and address: _______________________________________________________