Western Reserve Academy, C/O The Health Center 115 College Street, Hudson, Ohio 44236 Phone: 330.650.
9746 FAX: 330.650.5863 Email: mailto:healthcenter@wra.net
PHYSICIANS SCHOOL ENTRANCE EXAMINATION
A physical exam is required of new Academy students. It must be performed within 6 months prior to admission. STUDENTS NAME___________________________________________ DATE OF EXAMINATION ___________
(Last First M.I. )
Birth Date_______________ Sex M______F______ Height________ Weight_______ Pulse_______ Blood pressure_________ Vision: OD_____/_____ Corrected_____/_____ OS _____/_____ _____/_____ Hearing: Right_________ Left_________ Type of hearing test__________________________
IMMUNIZATIONS - Indicate the month/day/year each vaccine was given.
CURRENT IMMUNIZATION HISTORY
VACCINE
DTP, DT, Td, Tdap (Min. 4 doses, w/ Tdap booster within the last 10 years) POLIO VAC (4 doses, or 3 doses w/ last dose after 4 y.o.) MMR (Measles, Mumps, Rubella) HEP B VARICELLA (vs. Chickenpox disease or pos. titer) MENINGITIS (Highly recommended, not required) FLU VACCINE (Recommended annually) HPV (Gardasil; Cervarix Indicate type HEP A Other Other
*Required vaccine doses are starred, and your physician should provide any missing vaccines at the time of your childs school entrance physical. Other listed vaccines are highly recommended.
*1. *1. *1. *1. *1. 1. Date of last dose: 1. 1. 2. 2. 3. Type given: *2. *2. *2. *2. *2. *3. *Or month/year of disease or positive c. pox titer: *3. *3. *4. *4. 5.
TUBERCULOSIS (TB) TESTING IS REQUIRED for every new student, as mandated by Ohio Department of Health for Ohio colleges, universities and boarding schools. See strict instructions attached to this document.
NORMAL (Check box to indicate WNL) ABNORMAL (Please comment) NORMAL (Check box to indicate WNL) ABNORMAL (Please comment)
1. 2. 3. 4. 5. 6. 7.
Head, Neck, Face, Scalp Nose, Throat,
10. 11. 12. 13. 14. 15. 16.
Abdomen & Viscera Anorectal & Pilonidal Genito-Urinary & Reproductive Upper Extremities Lower Extremities Spine/Musculoskeletal Neurological
Gingiva, & Sinuses
Ears Canal, Drums, etc. Eyes Lids, Pupils, Movement Lungs, Chest, Breasts Heart, Vascular System Endocrine
PHYSICIANS ATHLETIC CLEARANCE This students physical and emotional capacity to participate in
athletics and all other facets of campus life is: _____FULL _____LIMITED (List specific restrictions on a separate page.)
Print Physicians Name ______________________________________ Phone number ____________________
PHYSICIANS SIGNATURE_____________________________________________________________________ *NOTE TO PHYSICIANS Please complete a WRA Medication Permission Form for each emergency medication or regularly taken medication (prescription or OTC) prescribed for this student.
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This information is strictly for the use of Health Services in providing necessary health care while you are a student at Western Reserve Academy. It will not be released to anyone without your knowledge and consent. This side is to be filled out by the student and/or parent and reviewed by your physician.
Have any of your relatives ever had any of the following? Yes No Relationship Tuberculosis Age at Death Diabetes Cause of Death Kidney Disease Heart Disease Arthritis Stomach Disease Brothers Sisters Asthma, Hay Fever Epilepsy, Convulsions
FAMILY HISTORY
Age Father Mother State of Health Occupation
PERSONAL HISTORY ALL QUESTIONS MUST BE ANSWERED. Comment on all yes answers in space below or on
additional sheet. DO YOU HAVE OR HAVE YOU EVER HAD?
Yes: Give year Chickenpox Measles German Measles Mumps Malaria Amoebic dysentery Gum or tooth trouble Sinusitis Eye trouble Ear, nose, throat trouble Surgery Appendectomy Tonsillectomy Hernia repair Worry or nervousness *Other No Recurrent Headache Recurrent colds Head injury with unconsciousness Hay fever Asthma Date of last attack Tuberculosis Shortness of breath Allergy Penicillin Sulfonamides *Other medicines Serum Foods (which) *Other Yes *Please explain in REMARKS / ADDITIONAL INFORMATION section. No Insomnia Frequent anxiety Frequent depression Chest pain / pressure Chronic cough Palpitations (heart) High or low blood pressure Rheumatic fever or heart murmur Disease or injury of joints Trick knee, shoulder, etc. Back problems Tumor, cancer, cyst Stomach or intestinal trouble Jaundice Gallbladder trouble or gallstones Eating disorder Seizures Learning problems ADD / ADHD REMARKS / ADDITIONAL INFORMATION (Attach an additional page if necessary.) Yes No Recurrent diarrhea Rupture, hernia Recent gain or loss of weight Dizziness, fainting Weakness, paralysis Sexually transmitted disease Albumin/sugar in urine or diabetes Frequent urination Kidney disease FEMALES ONLY Irregular periods Severe cramps Excessive flow Age of onset Birth control Method Permission for gyn exam Yes No
Yes Has your physical activity been restricted during the past five years? (Give reasons and duration.) Have you received treatment or counseling for a nervous condition, personality or character disorder, eating disorder, substance abuse, or emotional problem? (Give details.) Have you had any illness or injury or been hospitalized other than already noted? (Give details.) Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years? (Other than routine checkups.) Have you ever been immunized against tuberculosis with BCG vaccine? If yes, give date received. Do you have any question in regard to your health, family history, or other matters, which you would like to discuss now with a member of the staff of WRA Health Services?
No
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Rev. 3-11
