Child’s physical exam

CHILD’S PHYSICAL EXAM
Date Exam Scheduled: ______________
Date Exam Performed: ______________
Child’s name: _______________________________________
Date of Birth: ________________
Height: ______________
Weight: ________________
Temperature: _________________
Blood Pressure: ___________________________________
Immunization Dates:
DPT: _________________
Measles: __________________
Polio: ________________
Rubella: __________________
Hepatitis: _____________
Small Pox: _______________
Chicken Pox: _________
Other: ___________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Adenoids: _____________________________________________________________________________________
Chest:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Abdomen:
_____________________________________________________________________________________
Secondary Sex Characteristics: ____________________________________________________________________
Genitals:
_____________________________________________________________________________________
Reflexes:
_____________________________________________________________________________________
Extremities: _____________________________________________________________________________________
Posture and Spine: _______________________________________________________________________________
Nutrition:
_____________________________________________________________________________________
Signs of Endocrine Imbalance: _____________________________________________________________________
Menses:
_____________________________________________________________________________________

Treatment given: _________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Recommendations: _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Examining Physician Signature: _______________________________________________
Please print or type: ____________________________________________

(physician’s name)

Address:
_________________________________________________________
_________________________________________________________
I, the undersigned physician, give my permission for the foster parents to administer the following over-the-counter
medications to: ______________________________________________DOB:_______________
(Child’s name)
Type of Drug:
Examples:
__As directed on packaging
____Antacids and Acid Reducers
Tums,Rolaids;generic; or ___________________ or ___________________
Femstat 3, Gyne-Lotrimin, Mycelrx-7, Monistat
__As directed on packaging
____Anticandial
3, 7, and Vagistat-1; or ___________________
or ___________________
Actifed, Benadryl,Claritin, Chlor-Trimeton,
__As directed on packaging
____Antihistamines
Contac, Drixoral,Nyquil, Sudafed, Tavist-1, and
or ___________________
Triaminic,generic; or ___________________
Ex-Lax, Pepto-Bismol, Immodium A.D. and
__As directed on packaging
____Antidiarrheal and Laxatives
Kaopectate; or ___________________
or ___________________
____Anti-fungal
Lamisil AT, Lotramin AF, and Micatin;
__As directed on packaging
or ___________________
or ___________________
Bactine, Caldecort, Cortaid, Hydrocortisone,
____Anti-itch lotions and creams (e.g.,
and Lanacort,Calamine Lotion, Benadryl Cream, __As directed on packaging
for athletes foot, jock itch, bug
Caladryl, Cortaid,Lamisil AT, Lotramin AF, and
or ___________________
bites, poison ivy)
Micatin;
or ___________________
Robitussin, Vicks 44, Chloraseptic;
__As directed on packaging
____Cough Suppressants
or ___________________
or ___________________
Abreva Cream, Carmex; or
__As directed on packaging
____Cold Sore/Fever Blister
___________________
or ___________________
Advil Cold and Sinus, Afrin, Afrinol, Aleve Cold
and Sinus,Children’s Advil Cold, Duration,
Dristan Long Lasting,Neo-Synephrine- 12 Hour,
Orrivin, Sudafed,Tavist-D,Tylenol Cold and
____Decongestant/ Nasal
Flue, Thera-flu, Alka Seltzer Cold and Flu,
__As directed on packaging
Decongestant and Cold Remedies
Nyquil, Actidil Syrup and Capsules, Actifed,
or ___________________
Allerest,Benadryl, Claritin, Chlor-Trimeton,
Contac, Dimetane,Drixoral, Sudafed, Tavist-1,
and Triaminic;
or __________________
__As directed on packaging
____Eye Drops for Allergy/Cold Relief
Ocu Hist; or ___________________
or ___________________
Advil, Aleve, Children’s Motrin, Nuprin,
__As directed on packaging
____Internal Analgesic/antipyretic
Excedrin, Tylenol and Bayer; or
or ___________________
___________________
BenGay, Tiger Balm and Flexall; or
__As directed on packaging
____Liniments
__________________
or ___________________
Midol, Pamprin, and Premysyn PMS;
__As directed on packaging
____Menstrual Cycle Medications
or ___________________
or ___________________
____Migraine
Advil Migraine Liqui-gels, Excedrin Migraine,
__As directed on packaging
MotrinMigraine Pain, or ___________________
or ___________________
__As directed on packaging
____Pediculicide (head lice)
Nix; RID; or ___________________
or ___________________
____Toothache and teething pain
__As directed on packaging
Orajel; or ___________________
relievers
or ___________________
____Wart removal medications
Compound W; Tinamed or
__As directed on packaging
___________________
or ___________________

Physician Signature: ________________________________________________
Please print or type: ________________________________________________
(physician’s name)
Address:_________________________________________________________
Phone: __________________________________________________________

Source: http://www.bridgescpa.com/Physical%20Exam.pdf