Medical Evaluation Form

Medical Evaluation Form

Vital Signs

/

Hearing Assessment

Is conversation hearing normal?

Physical Examination

Check the appropriate response:

Body System Normal Abnormal Not Examined Significant Findings/Comments
Skin
EENT & Mouth
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Spine

Health Assessment Questions

1. If health conditions/pregnancy are present, does pregnancy or other health conditions create a limitation for the student participating in physical activities in the clinical area?

2. Does your examination reveal any infectious process?

3. List all current medication(s) (include Rx, OTC, herbal/vitamins)

4. Existing Medical Conditions?

Accepted formats: PDF, DOC, DOCX, JPG, JPEG, PNG
Maximum file size: 10MB

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