Clemmons First Baptist Church Preschool
PO Box 279
Clemmons, NC 27012
Phone: 336-766-1335
Fax: 336-766-1794
Preschool Physical Examination Form
Form to be filled out be a medical professional and returned to the above address
PO Box 279
Clemmons, NC 27012
Phone: 336-766-1335
Fax: 336-766-1794
Preschool Physical Examination Form
Form to be filled out be a medical professional and returned to the above address
Name of child______________________________________________________________________________________________Date of birth_____________________
(last) (first) (middle)
Address_________________________________________________________________________________________________________________________________
Sex______________________Height________________________Weight________________________
Hearing____________________________________________________________Vision________________________________________________________________
Do you consider that this child is in good physical condition to attend school?__________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Does this child have any physical restrictions?__________________________________________________________________________________________________
Does this child have any allergies? Specify: ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Does this child require any special medical treatment that we should be aware of?______________________________________________________________________
_______________________________________________________________________________________________________________________________________
Recommendations:________________________________________________________________________________________________________________________
IMMUNIZATIONS: ALL PRESCHOOL CHILDREN ARE REQUIRED TO BE UP TO DAT WITH IMMUNIZATIONS.
Please attach copy of completed immunizations.
Date of exam______________________________________________
Name of physician/clinic____________________________________________________________________________________________________________________
Signature_________________________________________________
Address__________________________________________________
________________________________________________________