Back-to-School Physical Examination Components
A comprehensive back-to-school physical should include a complete health history, physical examination with vital signs and growth assessment, developmental and psychosocial screening, immunization review and administration, and screening for specific conditions based on age and risk factors. 1
Essential History Components
Medical History
- Current medications (prescription, over-the-counter, herbal) with dosages and timing
- Allergies to medications and foods, including type of reaction
- Chronic medical conditions (asthma, diabetes, seizures, heart conditions)
- Previous hospitalizations and surgeries
- Family history focusing on premature cardiac death before age 50, sudden death, hypertension, diabetes, hyperlipidemia, and autoimmune diseases 1, 2
Birth and Developmental History
- Prenatal and birth history including gestational age
- Developmental milestones appropriate for age
- School performance and any learning difficulties (poor performance may indicate learning disabilities, ADHD, or bullying) 3
Lifestyle and Safety Assessment
- Nutrition: dietary habits and meal patterns
- Physical activity: aim for 60 minutes daily 4
- Sleep: 9-12 hours nightly for school-aged children 4
- Screen time: daily media use
- Dental care: last visit and fluoride supplementation status (if water supply has <0.6 ppm fluoride) 3
- Safety practices: seatbelt use, helmet use, firearm access
- Substance exposure: tobacco smoke, alcohol, drug use or exposure 1
Psychosocial Screening
- Mental health: screen for depression, anxiety, and behavioral concerns 1, 5
- Social determinants of health: food security, housing stability, transportation access, financial security, community safety 6
- Bullying and peer relationships
- Sexual activity (for adolescents) with confidential screening 1
Physical Examination
Vital Signs and Measurements
- Height and weight with BMI calculation and plotting on growth curves 7, 3
- Blood pressure (annually for hypertension screening) 3
- Heart rate
- Temperature
- Oxygen saturation (when indicated)
Focused Examination Areas
Cardiovascular System 2
- Auscultation in both supine and standing positions (or with Valsalva) to identify murmurs
- Femoral pulses to exclude aortic coarctation
- Blood pressure in both arms when possible
Musculoskeletal System
- Scoliosis screening (visual inspection of spine)
- Joint examination for swelling or limitations
- Gait assessment
- Sports-specific: comprehensive musculoskeletal exam if participating in athletics 5
Neurological System
- Age-appropriate developmental assessment
- Cranial nerve function
- Motor and sensory function
- Reflexes
Other Systems
- Skin: acanthosis nigricans (insulin resistance marker), signs of abuse
- Dental: oral health assessment
- Vision and hearing: screen approximately every 2 years 3
- Thyroid: palpation
- Abdomen: organomegaly, masses
- Genitourinary: Tanner staging for adolescents
Screening Tests
Universal Screenings
- Vision screening: approximately every 2 years 3
- Hearing screening: approximately every 2 years 3
- Obesity screening: BMI at or above 95th percentile requires referral for intensive behavioral interventions 3
Age-Specific Screenings
- Dyslipidemia: once between ages 9-11 years 3
- Anemia: if risk factors present
- Tuberculosis: if risk factors present 8
Risk-Based Screenings
- Depression: insufficient evidence for routine screening before age 12, but consider with unexplained somatic symptoms, restlessness, separation anxiety, phobias, or hallucinations 3
- STI screening: for sexually active adolescents 1
- Pregnancy testing: for pubertal girls who are sexually active 8
Immunizations
Review and administer age-appropriate vaccines per CDC/AAP recommendations 8, 1:
- Tdap booster
- HPV vaccine series
- Meningococcal vaccine
- Annual influenza vaccine
- COVID-19 vaccine
- Hepatitis B completion (if incomplete)
- Catch-up immunizations as needed 3
Anticipatory Guidance and Counseling
Health Promotion Topics
- Injury prevention: leading cause of death in school-aged children 4
- Nutrition: healthy eating habits
- Physical activity: 60 minutes daily 4
- Sleep hygiene: 9-12 hours nightly 4
- Dental care: twice-daily brushing, flossing, regular dental visits
Risk Reduction (Age-Appropriate)
- Tobacco, alcohol, and substance use avoidance
- Safe sexual practices (adolescents)
- Bullying prevention and response
- Internet safety and appropriate media use
- Violence avoidance
Special Considerations
For Athletes
If participating in sports, the examination should specifically address 2, 5:
- Personal history: exertional chest pain, unexplained syncope, excessive dyspnea with exercise, prior heart murmur
- Family history: premature cardiac death, cardiomyopathy, long-QT syndrome, Marfan syndrome
- Physical stigmata: Marfan syndrome features
- Musculoskeletal: comprehensive joint and flexibility assessment
Documentation Requirements
The examination should be documented in a format acceptable to the school, typically including 1:
- Confirmation that examination was completed
- Any restrictions or accommodations needed
- Immunization status
- Clearance for school activities and sports participation
Common Pitfall: Avoid "station-style" sports physicals that undermine the primary care relationship and fail to provide comprehensive preventive care 1. The back-to-school physical should ideally occur in the medical home setting with the child's primary care physician.