Grady EMS Academy
Physical Examination Form
Students must submit a physical examination form for admittance into all programs at Grady EMS Academy.
TO BE COMPLETED BY THE STUDENT
Student name: __________________________________________________________________________
Last name
First name
Middle initial
Students address: ______________________________________________________________________________
Street
City
State
Zip code
Date of birth (mm/dd/yyyy): _________
Phone: ____________________
Program: _______________________
Entrance date: _______________
Permission to Release Information – To be completed by STUDENT
As a student in a Grady EMS Academy health care or service program, I understand that:
I could be exposed to serious occupational hazards including orthopedic injury, stress, infectious disease, and hazardous chemicals
during my clinical/intern experience. For these reasons, I need to be in good health, and I thereby verify that all
information recorded here is accurate and complete.
I understand that all information contained in this report will be kept confidential according to law. I recognize that this
information might be of assistance in advising me in my clinical assignments: therefore, I herby give permission to
release the information contained in this report to Grady EMS Academy faculty or my clinical/intern program or
employer any information deemed necessary for the safety of myself, my clients, and other co-workers.
Signature of student: ________________________________
Date: ____________________
Grady EMS Academy Atlanta, Georgia
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Medical History – To be completed by the STUDENT
Have you had or do you have any of the following:
Yes No
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Allergies
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Drug or latex allergies
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Asthma
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Skin problems
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Kidney condition
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Back problems/lifting restrictions
Yes
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No
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Heart condition
Hepatitis
Diabetes
Tuberculosis
Hospitalizations/surgeries
Other chronic medical conditions
For each “Yes” above, give date(s) and explain: __________________________________________________________
_________________________________________________________________________________________________
Are you on medication?
□ Yes □ No
If “Yes”, please specify: _____________________________________
Physical Examination – To be completed by CLINIC PERSONNEL
Must be within the last year.
Height: __________
Weight: __________ BP: __________
P: __________ R: __________
Basic vision screening: ____________________________________________________________________________
Do abnormalities appear in any of the following systems?
Yes No
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Ears, eyes, nose, throat
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Cardiovascular
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Gastrointestinal
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Integumentary
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Respiratory
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Musculo-skeletal
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Neurological
If “yes” to any questions, please specify/explain.
MD/DO/PA/NP’s special recommendations regarding the health or physical limitations of this student while
participating in the program:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
MD/DO/PA/NP’s Statement and Signature:
I hereby certify this person has been examined by me as free from communicable disease and to be in good heath and
capable of participating in the named program at Grady EMS Academy.
________________________________________
MD/DO/PA/NP Signature
________________________________________
Telephone Number
________________________________________
Street Address
_________________________
Printed Name
_________________________
Date
_________________________
City, State, Zip
Grady EMS Academy Atlanta, Georgia
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