Student’s name

Today’s date

Date of birth

Age at time of exam

Gender

radioGender) && $my_application->radioGender == 'Male') checked @endif> Male

radioGender) && $my_application->radioGender == 'Female') checked @endif> Female

Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking

Does the student have any allergies?

radioAllergies) && $my_application->radioAllergies == 'No') checked @endif> No

radioAllergies) && $my_application->radioAllergies == 'Yes') checked @endif> Yes

If yes, list specific allergy and reaction

checkboxMedicines) ) ? 'checked' : '' }}> Medicines

checkboxPollens) ) ? 'checked' : '' }}> Pollens

checkboxFood) ) ? 'checked' : '' }}> Food

checkboxInsects) ) ? 'checked' : '' }}> Stinging Insects

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.

@else {{--라디오 생성 부분--}}

{{$data['idx']}}. {{$data['txt']}}

{'radioExamId'.$data['idx']}) && $my_application->{'radioExamId'.$data['idx']} == 'Yes') checked @endif> Yes

{'radioExamId'.$data['idx']}) && $my_application->{'radioExamId'.$data['idx']} == 'No') checked @endif> No

{{--사전 input 생성 부분--}} @if( ! empty( $data['finputtext'] ) ) @foreach($data['finputtext'] as $inputtext)

@endforeach @endif {{--체크박스 생성 부분--}} @if( ! empty( $data['checkbox'] ) )

@foreach($data['checkbox'] as $checkbox)

{'checkbox'.$checkbox['id']}) ) ? 'checked' : '' }}> {{$checkbox['txt']}}

@endforeach

@endif {{--추가 input 생성 부분--}} @if( ! empty( $data['inputtext'] ) ) @foreach($data['inputtext'] as $inputtext)

@endforeach @endif @endif @endforeach

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

STUDENT’S HEALTH HISTORY

Physical exam for grade

radioExamGrade) && $my_application->radioExamGrade == 'K1') checked @endif> K/1

radioExamGrade) && $my_application->radioExamGrade == '6') checked @endif> 6

radioExamGrade) && $my_application->radioExamGrade == '11') checked @endif> 11

radioExamGrade) && $my_application->radioExamGrade == 'Other') checked @endif> Other

{{--항목 영역--}} @foreach($ar_health_history as $key => $data)

{{$key}}. {{$data['txt']}} @if( ! empty($data['moretxt']) )

@endif @if( ! empty($data['checkbox']) )

{'checkboxPhyExam'.$key}) ) ? $my_application->{'checkboxPhyExam'.$key} : '' }}> {{$data['checkbox']}}

@endif

{'radioPhyExam'.$key}) && $my_application->{'radioPhyExam'.$key} == 'Normal') checked @endif> Normal

{'radioPhyExam'.$key}) && $my_application->{'radioPhyExam'.$key} == 'Abnormal') checked @endif> Abnormal

{'radioPhyExam'.$key}) && $my_application->{'radioPhyExam'.$key} == 'Defer') checked @endif> Defer

@endforeach

TUBERCULIN TEST

DATE APPLIED

DATE READ

RESULT/FOLLOW-UP

TUBERCULIN TEST

DATE APPLIED

DATE READ

RESULT/FOLLOW-UP

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

Parent/guardian present during exam:

radioParentPresent) && $my_application->radioParentPresent == 'Yes') checked @endif> Yes

radioParentPresent) && $my_application->radioParentPresent == 'No') checked @endif> No

Physical exam performed at:

radioPhyPerf) && $my_application->radioPhyPerf == 'Office') checked @endif> Personal Health Care Provider’s Office

radioPhyPerf) && $my_application->radioPhyPerf == 'School') checked @endif> School

Date of Exam

Name of examiner

examiner’s office address

Phone

Signature of examiner

HEALTH CARE PROVIDERS

Please photocopy immunization history from student’s record – OR – insert information below

IMMUNIZATION EXEMPTION(S): @for($i=1; $i<=3; $i++)

{'checkboxMedical'.$i}) ) ? 'checked' : '' }}> Medical

Date Issued

Reason

Date

Rescinded

@endfor

NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption

DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization

@foreach($ar_vaccine_list as $key => $value)

{{$key}}. {{$value}}

@for($j=1; $j<=5; $j++)

@endfor

@endforeach ADDITIONAL COMMENTS (PARENT I GUARDIAN I STUDENT I HEALTH CARE PROVIDER)

Private or School PHYSICAL EXAMINATION

OF SCHOOL AGE STUDENT

{{$data['title']}}

STUDENT’S HEALTH HISTORY

HEALTH CARE PROVIDERS