Name:

 FORMCHECKBOX  Boy   FORMCHECKBOX  Girl

Date of Birth:

Health Insurance:   FORMCHECKBOX  No    FORMCHECKBOX   Yes

Insurance Carrier:

Health History:

Allergies:  FORMCHECKBOX  No    FORMCHECKBOX   Yes, please list:

Asthma:  FORMCHECKBOX  No    FORMCHECKBOX   Yes

Is the child on any medications?:   FORMCHECKBOX  No    FORMCHECKBOX   Yes ~  If yes, which medication(s) and for what reason:

Height:

Weight:

Heart Rate:

Murmur:

B/P:

Lungs:

Abdomen:

ENT:

Genitalia:

CNS:

Seizure Disorder:   FORMCHECKBOX  no    FORMCHECKBOX  Yes                   

                                                                 Type:

Musculo-skeletal:

Scoliosis:    FORMCHECKBOX  Negative    FORMCHECKBOX   Positive   

                                                               Treatment:

Vision:  O.D. 20/                  O.S. 20/                          O.U. 20/

Hearing:         Right                            Left

Known Vision or Hearing Problem:

Development:                                                                           Speech:

Other significant medical information the school should know about:

Student may participate in all physical education activities:              FORMCHECKBOX   Yes                 FORMCHECKBOX   No

Student may not participate in the following physical activity(ies):

IMMUNIZATIONS:                                                                                      A copy of the immunization record is attached:   FORMCHECKBOX  Yes    FORMCHECKBOX   No

DPT/DT/DTaP:       

_________________________________________________________________

OPV/IPV:

____________________________________________________________________

MMR:

____________________________

HIB:

__________________________________________________

HBV:

____________________________________

Varivax:

                                     Or

Varicella date:

_______________

Meningitis Vaccine:

__________________

Mantoux:  Date given:

                         Date Read:                                 

Results:

Treatment:

Lead Level:

Date Tested:

Physician’s Name and Address (please print):

Physician’s Signature:

Telephone Number:

Date of Examination: