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School Physical Examination Form
Registration

School Physical Examination Form

3 pages•17 fields•HIPAA-ready
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School Physical Examination Form
Student Full Name
Date of Birth
School Name
Grade Level
Select...
Parent / Guardian Name
Parent Phone Number
Parent Email
Home Address
Immunization Records Upload
Upload file
Medical Conditions Checklist
Diabetes
Hypertension
Asthma
Heart Disease
Current Medications
Allergies
Vision or Hearing Concerns
Physical Activity Limitations
Parent / Guardian Signature
Sign here
Submit
Use this template

The School Physical Examination Form captures all the information needed for a child's annual school physical or school-entry health assessment. It combines student demographics, immunization records, medical history, and parent or guardian consent into a single streamlined form. This eliminates the need for parents to fill out multiple paper forms and ensures your practice has complete documentation before the appointment.

The form captures the child's demographic information along with the parent or guardian contact details, the school name and grade, and the student's complete immunization history. A medical conditions checklist covers common pediatric concerns including asthma, allergies, seizure disorders, diabetes, and behavioral health conditions. Parents can note any medications the child takes regularly, vision or hearing concerns, and physical activity limitations that the school nurse should be aware of.

Designed for pediatric practices, family medicine clinics, and school-based health centers that perform annual physicals and school-entry examinations. The form aligns with typical state school-entry physical requirements and can be easily customized to match your state's specific documentation standards. It saves significant time during peak back-to-school season when physical exam volumes surge.

What's included

  • Student demographics and school information
  • Parent or guardian contact and authorization
  • Immunization history with document upload
  • Medical conditions and allergy screening checklist
  • Vision, hearing, and activity limitation review
  • Parent signature and consent capture
  • Allergy documentation with severity levels
  • Medical conditions checklist
  • Structured medication list with dosage and frequency tracking

Who uses this template

  • Back-to-school annual physical examinations
  • School-entry and kindergarten health assessments
  • Camp and daycare physical requirements
  • Immunization record review and compliance documentation

All form fields

15 fields across 3 pages. Customize any field after signing up.

Student Full NameText
Date of BirthDate
School NameText
Grade LevelDropdown
Parent / Guardian NameText
Parent Phone NumberPhone
Parent EmailEmail
Home AddressText
Immunization Records UploadFile Upload
Medical Conditions ChecklistConditions
Current MedicationsMedications
AllergiesAllergies
Vision or Hearing ConcernsMultiple Choice
Physical Activity LimitationsLong Text
Parent / Guardian SignatureE-Signature

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$79.99/mo · Cancel anytime · HIPAA compliant

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