Clemmons First Baptist Church Preschool
PO Box 279
Clemmons, NC  27012
Phone:  336-766-1335
Fax:  336-766-1794

 Printable Preschool Physical Examination Form

Form to be filled out by 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 to be 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 DATE WITH IMMUNIZATIONS.
Please attach copy of completed immunizations.

Date of exam______________________________________________

Name of physician/clinic____________________________________________________________________________________________________________________

Signature_________________________________________________

Address__________________________________________________

________________________________________________________

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