CRESSET CHRISTIAN ACADEMY
SCHOOL PHYSICAL FORM
This Section must be completed only for:
(1) All new students
(2) Students entering grades K5, 3, 6, 9
(3) Yearly for sports participation (due before 1st day of practice)
PATIENT’S NAME _________________________________ BIRTH DATE ______________
The above patient is well and free of contagious disease except for _________________________
_______________________________________________________________________________
Weight: ____________ Height: ___________ Blood Pressure: ____________________________
Urinalysis: __________ Allergies: ___________________________________________________
Audio: _____________________ Vision: L20/_____________ R20/______________
Date of last tetanus booster: _________________ Date of last TB test: __________________
Immunizations received this visit: ___________________________________________________
Special needs and concerns:________________________________________________________
_______________________________________________________________________________
I find no contradiction to his/her participating in (name of sport) ___________________________
Comments:_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date of Exam __________ Signature of licensed physician: _____________________________
Physician’s name printed: ______________________________ Phone #: _________________
Forms/physical - student