Kentucky State University School of Education Student Teacher Medical Exam
Name: DOB: Exam Date:
Medial History (Completed in advance by student teacher applicant)
Please explain any medical and psychological history that could impede your ability to participate fully in student teaching:
Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings): ___
Medications: ___
Physical Examination (Completed by Health Care Provider)
General health: ___
Height:_____ weight:_____
blood pressure:_____ pulse:_____
___eyes/vision ___ears/hearing
___ nervous system ___ circulatory system
___ digestive system ___ musculoskeletal system
___dental respiratory system
___endocrine system
Tuberculin skin test or x-ray: date administered ___ date read: ___ results: ___
I certify that I have examined this individual and find him/her free of any medical problem or communicable disease that could interfere with his/her performing the duties of student teaching except as follows:
Printed Name
Updated 2/8/18
Signature
Date: