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