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Blinn College EMS Program Physical Form
Physical may be documented on the program form, or the provider form.
RELLIS Campus - Office: (979) 691-2130
Report of Health Evaluation
TO THE EXAMINING PHYSICIAN: Please review the students' history and complete the physician's form. Please comment on all positive answers. This information will be used only as a background for providing health care, if necessary.
| Student Name |
Blinn ID # |
| Blood Pressure |
Height in inches
Weight in pounds
|
ARE THERE ANY ABNORMALITIES OF THE FOLLOWING SYSTEMS?
| SYSTEM | YES | NO | COMMENTS |
|---|---|---|---|
| Head/Ears/Nose/Throat | |||
| Respiratory | |||
| Cardiovascular | |||
| Gastrointestinal | |||
| Hernia | |||
| Genitourinary | |||
| Musculoskeletal | |||
| Metabolic/Endocrine | |||
| Neuropsychiatric | |||
| Skin | |||
| Gynecological/OB | |||
| Are there any speech/vision/hearing impairments? | |||
| Eyes | Vision: Lt. Rt. Corrected: Yes No | ||
| Hearing | Hearing: Lt. Rt. Corrected: Yes No | ||
In your opinion, is this individual in suitable physical and emotional condition for this Health Science Program?
Unlimited
Limited
Please explain:
| Physician’s Signature |
Date |
| Physician’s Print Last Name First |
Office Number |
| Address City State Zip |
Office Fax |