SCHOOL ENTRY PHYSICAL FORM

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:

Last:

First:

Middle:

Birth Date:

ADDRESS:

Number, Street:

City:

Zip code:

School:

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:

Health History

Physical Examination

Dental Assessment

Nutritional Assessment

Vision Screening

Audiometric (hearing) Screening

Tuberculin Test (Mantoux/PPD)

Blood Test (for anemia)

Urine Test

Blood Lead Test

Other:

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:

First:

Second:

Third:

Fourth:

Fifth:

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

DATE EACH DOSE WAS GIVEN

First:

Second:

Third:

Fourth:

Fifth:

VACCINE: MMR (measles, mumps, and rubella)

DATE EACH DOSE WAS GIVEN:

First:

Second:

Third:

Fourth:

Fifth:

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

DATE EACH DOSE WAS GIVEN:

First:

Second:

Third:

Fourth:

Fifth:

VACCINE: HEPATITIS B

DATE EACH DOSE WAS GIVEN:

First:

Second:

Third:

Fourth:

Fifth:

VACCINE: VARICELLA (Chickenpox)

DATE EACH DOSE WAS GIVEN:

First:

Second:

Third:

Fourth:

Fifth:

Others:

First:

Second:

Third:

Fourth:

Fifth:

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

RESULTS AND RECOMMENDATIONS

Fill out if patient or guardian has signed the release of health information.

Examination shows no condition of concern to school program activities.

Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are:

:(please explain)

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.

Please check this box if you do not want the health examiner to fill out 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.

Signature of parent or guardian:

Date:

Health Examiner's Information

Name:

Address:

Telephone:

Signature of health examiner

Date:

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