Kentucky State University of Education Student Teacher Medical Exam

DOB: _____ Exam Date: _____

Medical History (Completed in advanced 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

___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 ___

<div style="text-align: center;"><img src="imgs/img_in_image_box_0_41_657_75.jpg" alt="Image" width="99%" /></div>

Signature

Date

Date