INCA HEAD START PHYSICAL EXAMINATION FORM
Revised 04/13
Classroom___________
Please return exam results to: INCA Head Start, PO Box 68, Tishomingo, Ok 73460 Office Use Only Date Entered on Child Plus ___/___/____
Date received by Health Manager_________
Parents: Head Start requires a physical exam, please return or fax this form when completed. (Head Start require un examen fisico, por favor regrese esta forma a Head Start cuando e doctor la complete.)
Child’s Name (Nombre):__________________________ Date of Birth (fecha de Nacimiento):_________ PHYSICIAN: Please complete the following three sections. 1—Mandatory Screenings: *Lead Test results:______ *HCT or HGB_______ Blood Pressure:____/____ Height:_______ Weight:______ 2—General Exam: Evaluation Normal Abnormal Evaluation Normal Abnormal Skin
Abdomen & Groin
Posture, Gait
Genitalia & Urinary
Speech, Communication Head
Bones, Joints
Eyes/Vision
Gross & Fine Motor
Ears/Hearing
Muscles
Nose
Cognitive
Mouth, Teeth
Self Help
Heart & Circulatory Chest & Lungs
Social Skills
Allergies
Neurological
Glands, Thyroid, Lymph Nutrition
3—Findings and Follow-up:
Normal Or Following conditions were discovered:________________________________________ _____________________________________________________________________________
Recommended Follow-up___________________________________________________
Provider Signature______________________________
Exam Date_________________
Clinic Name and Address________________________________________________________________