R.C.M. Academy (RCMA) The Military Academy of Canada by fqy94797


									                                                    R.C.M. Academy (RCMA)                                                                       RCMA-PEF 1020
                                                                                                                                                 Print Form
                                                "The Military Academy of Canada"
                                                             Physical Examination Form
                                To be administered by a physician holding a Canadian license to practice medicine
                                           IMPORTANT: ALL QUESTIONS MUST BE ANSWERED FULL
                             Students may no enroll without the physical exam. Exam must be administered within 6 months prior to entry.

Student's Name:                                                        Date of Birth:                            SIN, Social Security #:
                                     (First and Last Name)                                 (DD / MM / YYYY)

Physician's Name:                                                                                     Physician's Phone #:

Physician's Address:
                                                                       (Address / City, Provence and Postal / Zip Code)
Annual Required Test:
  Urinalysis:            1. Sugar                       2. Protein                    Microscopic: negative/positive (list results)
  Tuberculin Test: Negative                             Positive

  EXAMINING                             NORMAL                                            ABNORMAL, DESCRIPTION
  Chest, respiratory
  Heart, cardiovascular
  Skin, lymphatic
  Hernia, Genitalia defects
  Head, Nose, Throat

  Height:                           Weight:                        Blood Pressure:                                  Pulse:

Is there any known conditions which should be followed while student is at RCMA?                              Yes         No
If YES, would you like RCMA to monitor the condition or dispense any medications?                             Yes         No
Physician Remarks:

              ALLERGIES                                      MEDICATIONS / DOSAGES                                   ORTHOPEDIC APPLIANCE

I certify that I have examined this student as indicated and find him/her to be physically able to participate in any supervised physical activities that
are part of the curriculum NOT marked out:
           Baseball, Basketball, Cross Country, Golf, Swimming, Tennis, Track, Soccer, Volleyball, Wrestling (boys only)

I further certify that my examination and review, of the potential student's medical history, have revealed no condition which would constitute a
hazard to those who may be in close contact or proximity in our school environment.

 Physician's Signature                                                        Date (DD / MM / YYYY)                            E-mail Address
Student's Name:                                                                                 Date of Birth:

                                                            Medical History
            First two sections to be completed by the Family Physician and last section to be completed by parent / guardian
*Please complete or attaché a copy of Immunization Card.

       Immunization                     Date 1st       Date 2nd               Date 3rd           Date 4th                      Booster
       (Exact Dates Please)          (DD / MM / YY)    (DD / MM / YY)      (DD / MM / YY)       (DD / MM / YY)
  Small Pox
  DPT or DT Vaccine
  * Tetanus
  Oral Polio Vaccine
  HIB Vaccine
  Rubeola Vaccine
  Mumps Vaccine
  Rubella Vaccine
  MMR Vaccine                      #1                                    #2

*Most recent Tetanus Booster must have been within the last 10 years.
      Disease / Condition                              Date                        Disease / Condition                            Date
  A.D.D / A.D.H.D **                                                          Pink Eye
  Asthma                                                                      Pneumonia
  Chickenpox                                                                  Rheumatic Fever
  Diabetes                                                                    Rubeola / Rubella
  Epilepsy                                                                    Scarlet Fever / Tina
  Frequent Ear Infection                                                      Strep Infection
  Impetigo                                                                    Whooping Cough
  Mononucleosis                                                                Other:
  Mumps                                                                        Other:

** For A.D.D. / A.D.H.D., attach confirmation or evaluation by Physician or Psychologist.

Surgical Procedures:
                                               MENSTRUAL HISTORY (female applicants only)
Does applicant have the following menstrual cycle?        Monthly       Other (please put period rotation if not monthly)
Does applicant have the following menstrual cycle flow?         Heavy           Moderate          Low
Does applicant suffer from severe menstrual cramping that would impede
their ability to partaking in RCMA activities? Yes     No

                     Signature of Parent / Guardian                     Date (DD / MM / YYYY)                           Contact Number
Student's Name:                                                                       Date of Birth:

Screening: Your vision and hearing screening must be done by either your family physician or an ophthalmologist and Audiologist.

  VISION (This section must be completed)                      RIGHT                                   LEFT
  Uncorrected, near
  Uncorrected, distant
  Corrected, near
  Corrected, distant                                                                                                            I
  Color Discrimination                                                                                                          I
  Refractive Error                                                                                                              O
  External Health
  Glasses Prescribed?
  Contacts Prescribed?

A copy of current Complete Eyeglass or contact prescription, or spare pair of either should be given to the infirmary for emergencies.

                         Signature of Attending Physician                                               Date (DD / MM / YYYY)

                         HEARING                                      RIGHT                             LEFT
  Audiometer -                            500
                                          2000                                                                                  H
                                          3000                                                                                  A
                                          4000                                                                                  R
                                          5000                                                                                  N
  Hearing Aid Prescribed?
  Recommendation & Treatment Plan:

                         Signature of Attending Physician                                               Date (DD / MM / YYYY)

  POSTURAL SCREENING                            NORMAL                     ABNORMAL / DESCRIPTION                               S
  Scoliosis Screening                                                                                                           T

                         Signature of Attending Physician                                               Date (DD / MM / YYYY)
Student's Name:                                                                             Date of Birth:

Date of Last Exam:                                     Orthodontic or dental appliances prescribed?

                                 Dentist's Name                                                              Dentist's Phone Number

  If the above named pupil becomes seriously ill or injured at school and the family cannot be reached immediately for provision of
  instructions, I hereby authorize RCMA personnel to call and / or arrange for transportation of the pupil to our family physician.

  If this physician or dentist is not available, it is understood that the academy will call a doctor and / or will send the pupil, if
  necessary, to the nearest facility for emergency care.

  It is understood, further, that I will pay for any emergency transportation and for any subsequent emergency care, unless the costs
  are otherwise covered by insurance.

  We hereby consent to have the applicant receive emergency medical and dental treatment. We will notify the Academy of any
  changes in the applicant's medical status which may limit activities.

  (NOTE: Parents are responsible for notifying RCMA about any change of information contained on this form).

Date:                                  Signed by (Parent #1 or Guardian #1):

Date:                                  Signed by (Parent #2 or Guardian #2):

Please list the names of two (2) people to be contacted in an emergency if the parents cannot be reached :

  Full Name:                                                                  Phone Number:
  Address:                                                                              Relation to Child:

  Full Name:                                                                  Phone Number:
  Address:                                                                              Relation to Child:

                                         Application Selection Review Board
                                                   R.C.M. Academy
                                          "The Military Academy of Canada"
                                            5000 Yonge Street, Suite 1901
                                         Toronto, Ontario, Canada - M2N 7E9

Phone : 1 (416) 319-9688
E-mail : command@rcmacademy.ca
Website: www.rcmacademy.ca


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