Student Name (last, first, middle) ___

ID Number: _____ Date of Birth: _____

Seizures: ___

Chronic Illness: ___

Allergies: ___

Drug Allergies:

Medications: ___

Significant Historical Information: ___

___

N Abn

Hgt:_____ Wgt:_____ BP:_____/_____

___ ___ General Appearance

___ ___ HEENT Hearing: R ___ L ___

___ ___ Skin Vision: R ___/___ L ___/___

___ ___ Neck

Optional:

___ ___ Chest

HCT/HGB: ___ UA: ___

___ ___ Heart

___ ___ Abd-Genitalia

___ ___ Extremeties-Back (including scoliosis for 6^{th} grade)

___ ___ Neuro

Explain Abnormal Exam: ___

___

___ No restrictions - normal exam

Restrictions and suggestions to school:

___

Signed: ___ Date: ___

Physician/ARNP/PA/EPSDT Provider

Address:_____ Telephone: _____

Mail completed form to: Office of Admissions, Kentucky State University, ASB Suite 312,

Office of Admissions, Kentucky State University, ASB Suite 312,

400 E. Main St., Frankfort, KY 40601 or fax to (502) 597-5814

Rev 2/22/16