Health Examination Form

Document a clinical examination: allergies, asthma, seizures, diabetes, BMI percentile, lipids, blood pressure, vision, hearing and scoliosis screening. The provider signs off with their name, address and contact details. Widely used for school, camp and sports participation physicals.

Use this template

Full name

Nombre

Apellido

Date of birth

Sex

Female Male

Allergies

Yes No

Indicate the type of allergy

Asthma

Yes No

Indicate the type of asthma

Exercise-induced Allergic Persistent Intermittent

Seizures

Yes No

Indicate the type of seizure

Generalised Focal Absence Febrile

Date of last seizure

Diabetes

Yes No

Indicate the type of diabetes

Type 1 Type 2 Gestational Prediabetes

Measurements and vital signs

BMI (kg/m2)

Percentile (weight status category)

Underweight (below 5th percentile) Healthy weight (5th to 84th percentile) Overweight (85th to 94th percentile) Obese (95th percentile or above)

Hyperlipidaemia

Yes No Not screened

Hypertension

Yes No Borderline

Note any other relevant medical concerns (for example concussion, mental health, a single functioning organ)

Systems review and abnormal findings

Colour perception screening

Pass Fail Not tested

Medical clearance outcome

Cleared for all activities Cleared with restrictions Not cleared, pending further evaluation

Medical provider signature

Sign here

Provider name

Nombre

Apellido

Provider address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone number

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