PRIVATE PHYSICAL EXAMINATION
PRINT
OF SCHOOL AGE STUDENT
Student’s name
Today’s date
Date of birth
___
Age at time of exam
Gender: 
Male
___________________

Female
Page 1 of 1 PHYSICAL EXAM
STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes 
No 
Height:
(
) inches
Weight:
(
) pounds
BMI:
(
)
BMI-for-Age Percentile: (
Pulse:
(
*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS
DEFER
K/1 6 11 Other 
NORMAL
Physical exam for grade:
*ABNORMAL
CHECK ONE
)%
)
/
Blood Pressure: (
)
Hair/Scalp
Skin
Eyes/Vision
Corrected

Ears/Hearing
Nose and Throat
Teeth and Gingiva
Lymph Glands
Heart
Lungs
Abdomen
Genitourinary
Neuromuscular System
Extremities
Spine (Scoliosis)
Other
TUBERCULIN TEST
DATE APPLIED
RESULT/FOLLOW-UP
DATE READ
MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION
(Attach additional pages or write on back if needed)
Parent/guardian present during exam: Yes

No 
Physical exam performed at: Personal Health Care Provider’s Office

School 
Date of exam
20
Print name of examiner
Print examiner’s office address
Signature of examiner
Phone_
MD 
DO 
PAC 
CRNP 
Page 2 of 3: IMMUNIZATION HISTORY
HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.
IMMUNIZATION EXEMPTION(S):
Medical
Date
Issued:
Reason:
Date
Medical
Date
Issued:
Reason:
Rescinded:
Medical
Date Issued:
Reason:
Rescinded:
Rescinded:
Date
Date
NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.
VACCINE
DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Diphtheria/Tetanus/Pertussis (child)
Type: DTaP, DTP or DT
Diphtheria/Tetanus/Pertussis
(adolescent/adult)
Type: Tdap or Td
Polio
Type: OPV or IPV
Hepatitis B (HepB)
Measles/Mumps/Rubella (MMR)
Mumps disease diagnosed by physician
Varicella: Vaccine
Date:
Disease
Serology: (Identify Antigen/Date/POS or NEG)
i.e. Hep B, Measles, Rubella, Varicella
Meningococcal Conjugate Vaccine (MCV4)
Human Papilloma Virus (HPV)
Type: HPV2 or HPV4
Influenza
Type: TIV (injected)
LAIV (nasal)
Haemophilus Influenzae Type b (Hib)
Pneumococcal Conjugate Vaccine (PCV)
Type: 7 or 13
Hepatitis A (HepA)
Rotavirus
Other Vaccines: (Type and Date)
Page 3 of 3: PRE-PARTICIPATION PHYSICAL EVALUATION AND CERTIFICATION OF AUTHORIZED MEDICAL EXAMINER
For Sports Participation (Grades 6-8 only):
Student’s name
Date of birth
Today’s date
Age at time of exam
___
________________
Gender: Male
Female
A pre-participation physical examination and evaluation (pages 1 and 2) must be completed and signed by the Authorized Medical Examiner
(AME) performing the herein named student’s comprehensive initial pre-participation physical evaluation (CIPPE). This certification page (page 3)
must also be completed and signed by the Authorized Medical Examiner (AME). All pages must be turned in to the School Nurse, or designee, of
the student's school prior to any practices, inter-school practices, scrimmages, and/or contests in the sport(s).
I hereby certify that I have reviewed the health history, performed a comprehensive initial pre-participation
physical evaluation of the herein named student, and, on the basis of such evaluation and the student’s health
history, certify that, except as specified below, the student is physically fit to participate in practices, interschool practices, scrimmages, and/or contests in the sport(s) consented to by the student’s parent/guardian in
parent consent to participate form:
Sport(s) student athlete will be participating in:
(Check all that apply)
 CLEARED
 Cross Country  Soccer  Basketball  Tennis
 CLEARED, with recommendation(s) for further evaluation or treatment for:
 NOT CLEARED for the following types of sports (please check those that apply):
 COLLISION  CONTACT  NON-CONTACT  STRENUOUS  MODERATELY STRENUOUS  NON-STRENUOUS
Due to__________________________________________________________________________________
Recommendation(s)/Referral(s)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Parent/guardian present during exam: Yes

No 
Physical exam performed at: Personal Health Care Provider’s Office

School 
Date of exam
20
Print name of examiner
Print examiner’s office address
Signature of examiner
Phone_
MD 
DO 
PAC 
CRNP 