DIOCESE OF DALLAS

PHYSICAL EXAMINATION

NAME: ______________________________ D.O.B. ______________________

Please comment on any significant findings:

Height ________________ Weight ______________ Blood Pressure ________________ Pulse __________________

Vision: T. 20/____________ Lt. 20/__________ w/Corr__________ Hearing: R __________ L ___________

Abdomen _______________________________________ Limbs ____________________________________

Spinal ______________________ Bones & Joints ____________________ E.E.N.T. ________________

Mouth ______________________ Teeth ____________________________ Skin/Scalp: ______________

Chest ________________________________________ Reflexes __________________________________

Heart & Circulation _____________________________ Other ____________________________________

If there are any physical or emotional problems which may limit full school activity or that require special recommendations, please, advise: ___________________________________________________________

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Additional Comments/Impressions: __________________________________________________________

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PHYSICIAN’S SIGNATURE ______________________________________ DATE: ________________

PHYSICIAN’S TELEPHONE NUMBER ______________________________________________________