Exam Date: ___________ Annual Participation Health Screening School: Fayette County HS | Student's Name: | Date of Birth: | | Height ft._______ in._______ | Weight __________ lbs. | Blood Pressure: _____ / _____ | | Vision R 20/ _____ L 20/ _____ | Corrected Vision Yes No | Unequal Pupils Yes No | | | | MEDICAL | NORMAL FINDINGS | ABNORMAL FINDINGS | | Appearance | | | | Eyes | | | | Ears | | | | Nose | | | | Throat | | | | Lymph Nodes | | | | Heart | | | | Heart Murmur | | | | Pulses | | | | Lungs | | | | Abdomen | | | | Genitalia (males) | | | | Skin | | | | MUSCULOSKELETAL | NORMAL FINDINGS | ABNORMAL FINDINGS | | Neck | | | | Back | | | | Shoulder | | | | Arms | | | | Elbows | | | | Forearms | | | | Wrists | | | | Hands | | | | Hips | | | | Thighs | | | | Knees | | | | Legs | | | | Ankles | | | | Feet | | | CLEARANCE
Cleared for Participation Yes ____ No ____ Cleared for Participation AFTER follow up for : ____________________________________________________________________________________ NOT Cleared for Participation for: __________________________________________________________________________________ Recommendations/ Comments: __________________________________________________________________________________ Physician Name: (print clearly) _________________________________________ Date: _____________ Physician Signature: ___________________________________________________________________ | 
