KDE/MIC
APPROVED
1671-412
KENTUCKY DEPARTMENT OF EDUCATION
MEDICAL EXAMINATION OF SCHOOL EMPLOYEES *
Name_________________________________________ Birth date________________ Sex______________ WKU ID ____________________________ Address__________________________________________________ City ____________________________ Telephone Number_______________________ Applicant Employed by____________________________________________________________________ Board of Education____________________________________________________________________________________ Medical (All serious medical & psychiatric diseases: Diabetes, Epilepsy, Heart Disease, etc.) _________________________________________________________________________________________________ _________________________________________________________________________________________________ Surgical (All major operations) _________________________________________________________________________________________________ Traumatic History (T.B., Epilepsy, Diabetes) _________________________________________________________________________________________________ _________________________________________________________________________________________________ PHYSICAL 1. General Appearance ____________________ 7. Blood Pressure ___________ Pulse_______ 2. Eyes ______________________________________ 8. Lungs ___________________________________ 3. Ears, Nose, Throat _______________________ 9. Abdomen _______________________________ 4. Teeth and Gums __________________________10. Nervous System ______________________ 5. Thyroid ____________________________________11. Extremities ___________________________ 6. Heart _______________________________________12. Other __________________________________ _________________________________________________________________________________________________
TESTS Pos. Neg. Tuberculin or X-­‐ray . . . . . . . . . . . . . . ________________ _________________ CERTICATION OF MEDICAL EXAMINATION This is to certify that I have examined ____________________________________________, and find him/her free of communicable disease and any physical or mental disabilities that might interfere with performing his/her duties, except as follows: _________________________________________________________________________________________________
________________________________________________________________________________________________ __________________ __________________________________________________________, M.D. Date of Examination Signature