DOB: _____ Exam Date: _____
Name: ___
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:
General health: ___
Height: ___ weight: ___ blood pressure: ___ pulse: ___
___eyes/vision ___ears/hearing
___ nervous system ___ circulatory system
___musculoskeletal system
___ digestive 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 performing the duties of student teaching except as follows:_____
Distributed Memory
Printed Name
___
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Signature
Date
Date