Physical Examination Record Form
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1Physical Examination Record
Name (Last, First, MI)
Parent/Guardian
Address(# and street)
Date of Birth
Age
Sex
City/Town
State
Zip
Phone
Emergency Contact
Address
Phone
Diseases
Allergies
Chronic/Reoccurring Illness
Suggestions from
Parent/Guardian
□ Chicken Pox
□ Animals
□ Medicine/ Drugs
□ Ear Infections
□ Asthma
□ Measles
□ Food
□ Plants
□ Heart Defect/
□ Hypertension
Disease
□ German Measles
□ Hay Fever
□ Pollens
□ Seizures
□ Diabetes
□ Mumps
□ Insect Stings
□ Other
□ Bleeding
□ Musculoskeletal
Disorders
Disorders
□ Other
______________
Please describe conditions and give dates:
Operation or serious injuries:________________________________________________________
Hospitalization:___________________________________________________________________
Other diseases/disabilities:__________________________________________________________
Comments where applicable:
Fainting:_________________________________________________
Sleep Disturbances:__________________________________
Bed wetting:______________________________________________
Menstrual Cramps:___________________________________
Constipation:_____________________________________________
Nosebleeds:________________________________________
Emotional disturbances:_____________________________________
Other:____________________________________________
Specific activities to be encouraged:___________________________
Special Medical or dietary regimen to be followed
(specify):__________________________________________
This health history is complete and accurate. My daughter has permission to engage in all prescribed activities, except as
noted by me and the examining physician.
Signature of parent/guardian:____________________________________________________________________________________
Section to be filled in by physician after review of health history with
Immunization
Year Primary
Year of last
parent/guardian:
Series
booster
Completed
Date of examination:_______________________________________
DTP
____________
__________
Height:
Weight:
B.P.
Diphtheria
____________
__________
Appearance/Nutrition:______________________________________
Pertussis
____________
____________
(whooping cough)
Eyesight (w/o glasses): R 20/____ L 20/____ (w/glasses): R 20/____ L 20/____
Tetanus
____________
____________
Ears:____________________________ Hearing: R_____ L_____
Td **
____________
____________
Color vision:________________________________________________________
Oral polio
____________
____________
Code:
Nose:____________________________________________
Measles
____________
____________
Throat:___________________________________________
Mumps
____________
____________
√ - satisfactory
Teeth:____________________________________________
Rubella
____________
____________
Heart:____________________________________________
Hib **
____________
____________
X - not
Lungs:____________________________________________
Hep B
____________
____________
satisfactory
Abdomen:_________________________________________
Tuberculin test
Last year given_______________
O - not examined
Genitalia:_________________________________________
Result______________________
Hernia:___________________________________________
Other
____________
____________
Skin:_____________________________________________
Physician’s comments and recommendations.
Musculoskeletal:____________________________________
Give details or indicate management of significant.
General physical and emotional status:__________________
____________________________________________
Urinalysis: *_______________________________________
____________________________________________
Other Notes:_______________________________________
____________________________________________
*
Not required for every physical examination. A Daisy, Brownie, or
This person is in satisfactory condition and may engage
Junior Girl Scout should have this test if she has not already had it,
in activities except as noted.
wither when entering school or at any time since. A Cadette or Senior
Physician’s name
______________ Date________
Girl Scout should have this test if she has not had it since entering
(print)
puberty.
Physician’s signature___________________________
Address_____________________________________
City/State/Zip________________________________
** Adult tetanus-diphtheria toxoid
*** Haemophilus influenza b
Phone_______________________________________
5-16-Physical Examination Record Rev 3-21-12 pg
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Parent category: Medical