SCHOOL ENTRY PHYSICAL FORM

Please correct the errors described below.

REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY

To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information.

PART I | TO BE FILLED OUT BY A PARENT OR GUARDIAN

CHILD'S NAME:

ADDRESS:

PART II | TO BE FILLED OUT BY HEALTH EXAMINER

HEALTH EXAMINATION NOTE:

All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age.

REQUIRED TESTS/EVALUATIONS:

IMMUNIZATION RECORD:

Note to examiner: Please give the family a completed or updated yellow California Immunization Record. Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).

VACCINE: Polio (OPV or IPV)

DATE EACH DOSE WAS GIVEN:

VACCINE: DtaP/DPT/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only)

DATE EACH DOSE WAS GIVEN

VACCINE: MMR (measles, mumps, and rubella)

DATE EACH DOSE WAS GIVEN:

VACCINE: HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only)

DATE EACH DOSE WAS GIVEN:

VACCINE: HEPATITIS B

DATE EACH DOSE WAS GIVEN:

VACCINE: VARICELLA (Chickenpox)

DATE EACH DOSE WAS GIVEN:

PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional) And RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN

RESULTS AND RECOMMENDATIONS

I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Health Examiner's Information

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