(Print this Page and Return the Completed Form)

ANGELS UNLIMITED PRESCHOOL
HEALTH INFORMATION PAGE 2
TO BE COMPLETED BY A PHYSICIAN

Name:___________________________  Date: _______________________

Height:__________________              Weight: _______________

Blood Pressure:_______________    Hemoglobin or Pct.:__________________

Eyes:  Glasses worn?: _______            Vision: R 20/ ____ L 20/____

Ears: Hearing Aid Worn?: _____          Hearing: R____ L_____

Development Normal: ______________          Speech Normal: _________________

List Positive finds of complete medical examination:_____________________________

Is there a condition which may limit participation in:

Classroom activity?:___________________________________________________

Physical  activity?:______________________________________________________

Doctor’s Signature: _________________________________________________

Address: ______________________________________________________________

Telephone:________________________

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