Mary Bray School
 Dorothy Kozmoski, RN
 931-7807

MOUNT EPHRAIM PUBLIC SCHOOLS
PHYSICAL EXAMINATION RECORD

R. W. Kershaw School
 Elisa Keane, RN
 931-1634

 
Child's Name___________________________________________________________________________ 
                                       Last                                                     First                                                  Date of Birth

Address                                                                                             Phone #                                                                            

Parent(s)/Guardian’s Name                                                                                                                                                        
                                                                        Last                                                                       First
 

Record of Immunizations
      

DPT-1st                             2nd                               3rd                                 Booster                               Booster                       
Polio-1st                            2nd                               3rd                                 Booster                               Booster                        
Measles/MMR-1st _____________  2nd                               
HIB-1st                                                     2nd                                3rd                                      
Hepatitis B-1st                                        2nd                                 3rd  ______________
Varicella   ____________________
Mantoux                                                   Result                                        

Health History
    

Chicken Pox  _______________________________   Congenital Defects _______________________________
Eczema/Psoriasis  ___________________________      History of Heart Trouble __________________________
Ear Infections ______________________________     History of Lung Trouble ___________________________
Rheumatic Fever ___________________________     Family History of Diabetes _________________________
Seizure Disorder ____________________________     Other _________________________________________
Asthma __________________________________    Operations _____________________________________
Sinusitis _________________________________      Hospitalizations_________________________________
Diabetes _________________________________      Under Doctor’s Care _____________________________
Allergies _________________________________
 

Doctor’s Examination
       

Height                                           Weight                               Blood Pressure _____________________________
Posture ___________________________________ Feet _____________________________________
Extremities _________________________________ Heart ____________________________________
Nutrition __________________________________ Nervous System ____________________________
Skin ______________________________________ Lungs ____________________________________
Teeth _____________________________________ Abdomen _________________________________
Throat ____________________________________ Hernia ____________________________________
Ears ______________________________________ Genitals ___________________________________
Eyes ______________________________________ General Condition ____________________________
 

                                                                                                              ___________________________
Date                                       Physician’s Signature                                              Physician’s Stamp