Physical Examination Form (To Be Filled Out By Physician) printable pdf download

PHYSICAL EXAMINATION FORM

Application Package

(TO BE FILLED OUT BY PHYSICIAN)

Height ____________________________________

Skin _____________________________________________

Heart _____________________________________

Weight ___________________________________________

Temperature _______________________________

Lungs ____________________________________________

Pulse _____________________________________

Blood Pressure _____________________________________

Respiration ________________________________

Abdomen _________________________________________

Urinalysis _________________________________

1. Do you consider this student physically and emotionally capable of doing college work? Yes

2. Is a normal class load advised? Yes

If no, give reason/s __________________________________

______________________________________________________________________________________

3. Is any medical care to be continued while the student is attending school?

Yes

4. Is there any reason why this person should not undertake normal manual labour?

Yes

5. Remarks (any special health problems or precautions): _______________________________________________

______________________________________________________________________________________

Name of Physician: ______________________________________________________

Signature of Physician: _____________________________

Date of examination: _____________________

Address of Physician:

______________________________________________________________________________________________________

Physician’s

Stamp

JANUARY 2015

F30

REV. 1

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Physical Examination Form (To Be Filled Out By Physician)