MIDDLETOWN TOWNSHIP PUBLIC SCHOOLS

Middletown, NJ 07748
www.middletownk12.org






Date:__________________


Dear Parent/Guardian:

In accordance with New Jersey Administrative Code 6A:16-2.2, each student must be
examined by a physician, nurse practitioner, or physicians assistant upon entry into the
school district. This examination must be done no more than 365 days prior to entry
and must state what, if any, modifications are required for full participation in the school
program.

The Board of Education recommends obtaining subsequent physical examinations at
least once during each of the students development stages:
Early childhood (preschool through grade 3)
Pre-adolescence (grades 4 through 6)
Adolescence (grades 7 through 12)

If your student is transferring into this district, documentation of a physical exam within
365 days of entry is required.

Thank you for your cooperation,


School Nurse
Exam form on back
NRB:mn


(over)



MIDDLETOWN TOWNSHIP PUBLIC SCHOOLS
Middletown, N.J. 07748
www.middletownk12.org

ROUTINE MEDICAL EXAMINATION FORM

Students Name ___________________________________ Date of Birth _________________

Parents Name ____________________________________ Telephone __________________

Address _____________________________________________________________________

School ______________________________________________________________________



Normal Abnormal Comments
Skin
Eyes/Sclera/Pupil
Ears
Nose
Throat/Mouth
Heart/Rhythm
Lungs/Ausculation/Percussion
Abdomen/Liver/Spleen
Blood Pressure & Pulse
Nervous system
Hernia
Orthopedic Defects (Specify)
Height
Weight

Heart Murmur Yes_____ No _____ Restriction Activity _________________________

Immunization Update ____________________ Hepatitis B _____________________________

Date of Last TB Mantoux Test ____________________ Result _________________________

_______________________________ ________________________________________
Physicians Name (Please Print) Physicians Signature

Date of Examination ________________


9/02