Student Physical Form - Leavenworth Unified School District 453 - usd453 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the student's name and birth date in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Indicate the student's gender by selecting either Male or Female. This helps in maintaining proper records.
4. Fill in the address, city, and zip code of the student’s residence. This information is essential for school communications.
5. Provide details of the parent or guardian, including their name and contact numbers (cell and home). This ensures that the school can reach out if necessary.
6. Complete the coding section by assessing each item based on findings from the health examination. Use '0' for no significant findings and '1' for significant findings.
7. Document vital signs such as height, weight, blood pressure, pulse, vision, and hearing in their respective fields.
8. Include any significant assessment findings related to asthma or allergies in the provided space.
9. Sign and date at the bottom of the form where indicated by a licensed physician or nurse.
10. Finally, ensure that a parent/guardian signature is obtained along with the date to authorize health record transfers.

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