Norfolk Public Schools Physical Examination Form

GRADE STUDENTS WILL NOT BE ABLE TO START THE SCHEDULE PICKUP PRO-

CESS IN AUGUST UNTIL THE REQUIRED PAPERWORK EXPLAINED BELOW IS COM-

PLETED .

PHYSICAL - The Nebraska state law requires a completed PHYSICAL signed by a

doctor or a WAIVER signed by the parent or the guardian PRIOR to entering 7

grade. The physical or waiver needs to be completed & returned to school prior

to schedule pick up dates or on the day of schedule pick up.

According to NSAA athletic bylaws, a sports physical must be completed after May

1, 2024.

TDAP BOOSTER AND IMMUNIZATIONS- 7

graders must have documentation of a

TDAP immunization as required by the state of Nebraska.

Parents, please note these papers MUST be provided to the school. If the school does

not have these papers, the student will not be able to participate in the schedule pick

up process until we have received the paperwork.

Name_________________________________________ DOB__________ SEX_____ GRADE__

Physician___________________________ Clinic_________________ Allergies____________

Please complete prior to exam.

Do you take any supplements or vitamins to help with weight loss or weight gain? Yes___ No___

What do you think is your ideal weight? ____ Lowest weight last year ______ Highest

weight______

Are there any medical concerns you would like to discuss with the doctor? ________________

____________________________________________________________________________

Physical Examination

Height ______ Weight ____________ Heart _________ Thyroid ____________

Blood Pressure _________ Pulse _________ Lungs Abdominal Organs _______

Urinalysis _______ Hemoglobin/HCT ______ Evidence of Hernia _______________

Orthopedic Exam:

Neck __________ Upper Extremities___________ Spine _______________

Knees __________ Lower Extremities ___________ Evidence of Scoliosis___________

Feet __________ Mouth __________Dental cavities needing treatment______________

Vision Screening: Audiometric Screening Report

OD_______ OS _______ 1000 2000 4000

With glasses OD_______ OS _______ RE __________________

LE __________________

Immunizations: Seventh grade students are required to have a Tdap booster. Please

list

the dates of updated vaccinations.

TDAP _________ Varicella#1__________ #2___________or Date of dis-

ease__________ __

Other immunizations ( These are not required by state law but may be administered per your doc-

tor’s advice.)