Norfolk Public Schools Physical Examination Form
7
TH
GRADE STUDENTS WILL NOT BE ABLE TO START THE SCHEDULE PICKUP PROCESS
IN AUGUST UNTIL THE REQUIRED PAPERWORK EXPLAINED BELOW IS COMPLETED .
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
th
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,
2022.
TDAP BOOSTER AND IMMUNIZATIONS- 7
th
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 disease__________ __
Other immunizations ( These are not required by state law but may be administered per your doctor’s
advice.)
HPV_________ Meningococcal_____________ Hepatitis A____________
Medical health problems: History of heat stroke/ exhaustion________ Heart murmur ____
Seizures_______ High blood pressure______ Diabetes_________ Sickle Cell Disease______
Abnormal bleeding________ Hepatitis______ History of loss of consciousness/head injury_______
Asthma Yes____ No____ Treatment_____________________________________
Required medication on a daily or episodic routine:
________________________________________________________________________
Physical Activity: Unrestricted _____ Modifications or Exceptions _________________
Remarks and suggestions
_______________________________________________________________________________
I certify that I have on this date examined this student and that, on the basis of the examination
requested by the school authorities and the student's medical history as furnished to me, I have found no
reason which would make it medically inadvisable for this student to compete in supervised athletic
activities, EXCEPT THOSE CROSSED OUT.
FOOTBALL TRACK BASKETBALL VOLLEYBALL CROSS COUNTRY WRESTLING
Date _____________ Print Physician Name ___________________________
Physician Signature _______________________________
Physical Waiver
Please fill out the section below ONLY if you wish to WAIVER the physical. This must be signed by
the parent or guardian.
As the Parent/Guardian of __________________________ Birthdate__________Grade_______
I do not wish that my child have a physical examination.
_______________________________________ ____________________________
Signature Date
