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931-896-1800

CMCCAA HEAD START PHYSICAL FORM

Email Address *

LAST NAME, FIRST NAME, MIDDLE INITIAL OF CHILD *

SEX *MaleFemale

DATE OF BIRTH *

NAME OF PATIENT OR GUARDIAN *

AGENCY NAME *

SITE NAME *

TO BE COMPLETED BY HEALTH CARE PROVIDER

PHYSICAL EXAMINATION ADMINISTERED BY (TYPE OR PRINT NAME) *

SIGNATURE *

CLINIC NAME *

TELEPHONE NUMBER *

DATE OF EXAM *

Street Address *

City *

State/Province *

ZIP / Postal Code *

EXAMINATION RESULTS

HEIGHT *INCHES (%)

WEIGHT *LBS/OZ (%)

WEIGHT *BMI FOR AGE (%)

HEAD *Circumference

ANTICIPATORY GUIDANCE PROVIDED *YESNO

FLUORIDE VARNISH APPLIED *YESNO

EXAM

NORMAL

ABNORMAL

Blood Pressure (3+)

Skin

Head

Neck

Lymph Nodes

Eyes

Ears

Nose

Mouth/Teeth/
Oral Health Assessment

Throat

Chest

Lungs

Heart

Back

Abdomen

Genitalia

Neurologic

Extremities

Motor Ability

Psychological

Speech

Hearing Assessment

Vision Assessment

Vision Acuity (Age 3+)

DATE *

TEST TYPE *

Right *

Left *

Both *

Hearing Screening (Age 4+)

DATE *

TEST TYPE *

Frequency (Hz)

1000Hz

Right (db) *

Left (db) *

Frequency (Hz)

2000Hz

Right (db) *

Left (db) *

Frequency (Hz)

3000Hz

Right (db) *

Left (db) *

Frequency (Hz)

4000Hz

Right (db) *

Left (db) *

Hemoglobin

DATE *

HGB (g/dl) *

No Risk Anemia

TREATMENT *

DATE OF FOLLOW UP *

Lead

DATE *

Lead Level (mcg/dl) *

No Risk

Medicaid requires at least one lead level between 24 & 72 months
*Hemoglobin and Lead level required to be complete physical

Screening of TB Risk Factors

Risk factors NOT present: TB Skin Test NOT RequiredRisk factors present: Mantoux TB skin test performed

DATE GIVEN *

RESULTS (mm) *

Non SignificantSignificant

DATE READ *

DATE OF CHEST XRAY *

RX DATE *

NormalAbnormal

Dyslipidemia Screening *ScreeningRisk Factors PresentNo Risk

Immunization *Given TodayYesNo

Date (or Age) Next Physical Exam Due

Diagnoses/Abnormal Findings *

Treatment/Restrictions/Recommendations for School *

MEDICATIONS REQUIRED AT SCHOOL *(If yes, Physician Authorization Forms Needed)YesNo

Type of Medication and Purpose

*Please return form to:
CMCCAA Head Start
150 Lafayette, Rd. Clarksville, TN 37042
Phone: (931) 896-1808 Fax: (931) 542-4616

Save & Finish Later

We're a Community Action Agency serving Clarksville-Montgomery County, created back in 1964 to help fight poverty. We're here to support local families with everyday services and programs that make life a little easier.

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Phone: 931-896-1800
Address: 150 Lafayette Road Clarksville, TN 37042

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