Academy of Our Lady
180 Rodney Street Glen Rock, New Jersey 07452
(201) 445-0622 - FAX (201) 445-8345
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Student Name:____________________________________________ |
Birth Date:__________________ |
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Address:______________________________________________________ |
Phone #:____________________ |
Physical Exam
| Exam Date: | TB Screening | Other |
| Height | Date | |
| Weight | Result | Full Participation |
| B/P | Test Type | Yes |
| Vision | No | |
| Without glasses | Physical Exam | Limitations |
| Right eye | Ears (otoscopic) | |
| Left eye | Eyes | ALLERGIES |
| Both eyes | Lymph | |
| With glasses | Thyroid | |
| Right eye | Nose | |
| Left eye | Throat | MEDICAL HISTORY |
| Both eyes | Teeth/Mouth | Diseases - |
| Muscle balance | Heart | |
| Color perception | Lungs | |
| Abdomen | ||
| Hearing | Hernia | Operations - |
| Right ear | Genito-Urinary | |
| Left ear | Orthopaedic | |
| Skin | ||
| Scoliosis Screen | Nutrition | Injuries - |
| Normal | Nervous System | |
| Positive | Speech | |
| Referred | General Appearance |
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Stamp
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Physician's Name (Please Print) |
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Physician's Signature Date |
Immunization Record
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Disease Date |
1st Dose |
2nd Dose |
3rd Dose |
4th Dose |
5th Dose |
6th Dose |
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DPT |
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Polio |
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MMR |
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Measles |
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Serology: |
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Titer: |
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Rubella |
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Serology: |
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Mumps |
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Serology: |
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Titer: |
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HIB |
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Hepatitis B |
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Chicken Pox |
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Provisional Admission: ____ Date:____________ EXEMPTION ATTACHED: Medical ___ Religious ____