Clemmons First Baptist Church Preschool
PO Box 279
Clemmons, NC 27012
Physical Examination
(Form to be filled out by doctor and returned to the above address)
Name of Child_________________________________________________________Date of Birth_________________
(last) (first) (middle)
Address_______________________________________________________________Telephone__________________
Sex_____________________________Height_________________________Weight____________________________
Hearing_______________________________________Vision_____________________________________________
Do you consider that this child is in good physical condition to attend school?_____________________________________
_______________________________________________________________________________________________
Does he have any physical or other restrictions?___________________________________________________________
_______________________________________________________________________________________________
Does he have any allergies? Specify:____________________________________________________________________
________________________________________________________________________________________________
Does he require any special treatment that we should know about?___________________________________________________
_____________________________________________________________________________________________________________
What communicable diseases has he had?_________________________________________________________________________
_____________________________________________________________________________________________________________
Immunizations completed:_______________________________________________________________________________________
_____________________________________________________________________________________________________________
Recommendations:_____________________________________________________________________________________________
Signature_________________________________________________
Date of Examination_______________________________________
