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: