Student Health Record
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1
2Department of Education
S
’
H
R
TUDENT
S
EALTH
ECORD
Student Address Label
❑
/
/
Name
Preschool:
Entry Date
Female
(Last)
(First)
(Middle Initial)
❑
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/
Male
Elementary:
Entry Date
Birthdate
/
/
Intermediate/Middle: Entry Date
Month
Day
Year
/
/
High:
Entry Date
Parent’s Name
(Mother/Guardian)
(Father/Guardian)
Please complete the following sections (CHECK IF YES)
M
S
EDICAL
TATUS
❑
❑
❑
❑
Allergy (type)
Cancer/Leukemia
Hearing Problems
Rheumatic Heart
❑
❑
❑
❑
Asthma
Chronic Cough/Wheezing
Heart Disease
Sickle Cell Anemia
❑
❑
❑
❑
Vision Problems
Diabetes
Hemophilia
Seizures
P
’
E
C
: N-N
; A-A
; C-C
; R-R
C
HYSICIAN
S
XAMINATION
ODE
ORMAL
BNORMAL
ORRECTED
ECEIVING
ARE
Varicella
Vision
Hearing
Immunity
Significant Findings
Provider’s Stamp
Date
Secondary to
Provider’s Signature
or Printed Name
and Recommendations
Disease (DATE)
R. L. R. L.
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T
E
I
*
UBERCULOSIS
XAMINATION
(V
, D
G
: M
/D
/Y
)
MMUNIZATIONS
*
ACCINES
ATES
IVEN
ONTH
AY
EAR
Y
N
Y
N
M
T
(I
)
ANTOUX
EST
NTRADERMAL
Polio
HIB Haemophilus
Physician, APRN, PA, or Clinic
DTaP, DTP, DT, or Td
Hepatitis B
Varicella
MMR
Date
Date
Results
(IPV or OPV)
influenzae type B
DTaP
(Signature or Stamp if Different
Given
Read
(mm)
❑ ❑
from Above)
Date Given
Type
Date Given
Date Given
Type
Date Given
Date Given
Type
Date Given
❑ ❑
Polio
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❑ ❑
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❑ ❑
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HIB
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❑ ❑
❑ ❑
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HEP
C
X-R
HEST
AY
❑ ❑
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Results
Location
Date
MMR
❑ ❑
Measles
OTHER
/
/
❑ ❑
/
/
Varicella
Date Given
❑ ❑
Type
Date Given
Date Given
Mumps
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❑ ❑
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D
E
ENTAL
XAMINATION
Rubella
❑ ❑
Dental Check-Up
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Physician, APRN, PA or Clinic
(Signature or stamp if different from above)
*OFFICE USE ONLY (Rev. 2002)
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