Report Form Of Health Examination For School Entry printable pdf download

State of California—Health and Human Services Agency

Department of Health Care Services

Child Health and Disability Prevention (CHDP) Program

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—Month/Day/Year

ADDRESS—Number, Street

City

ZIP code

SCHOOL

PART II

TO BE FILLED OUT BY HEALTH EXAMINER

HEALTH EXAMINATION

IMMUNIZATION RECORD

Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.

NOTE: All tests and evaluations except the blood lead test

Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).

must be done after the child is 4 years and 3 months of age.

REQUIRED TESTS/EVALUATIONS

DATE (mm/dd/yy)

DATE EACH DOSE WAS GIVEN

Health History

______/______/______

VACCINE

First

Second

Third

Fourth

Fifth

Physical Examination

______/______/______

POLIO (OPV or IPV)

Dental Assessment

______/______/______

DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular]

Nutritional Assessment

pertussis) OR (tetanus and diphtheria only)

______/______/______

Developmental Assessment

______/______/______

MMR (measles, mumps, and rubella)

Vision Screening

______/______/______

HIB MENINGITIS (Haemophilus Influenzae B)

Audiometric (hearing) Screening

(Required for child care/preschool only)

______/______/______

TB Risk Assessment and Test, if indicated

______/______/______

HEPATITIS B

Blood Test (for anemia)

______/______/______

VARICELLA (Chickenpox)

Urine Test

______/______/______

OTHER (e.g., TB Test, if indicated)

Blood Lead Test

______/______/______

Other

______/______/______

OTHER

PART III

ADDITIONAL INFORMATION FROM HEALTH EXAMINER (

)

and

RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN

optional

I give permission for the health examiner to share the additional information about the health

RESULTS AND RECOMMENDATIONS

check-up with the school as explained in Part III.

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

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

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)

Signature of parent or guardian

Date

Name, address, and telephone number of health examiner

Signature of health examiner

Date

If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health

department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.

CHDP website:

PM 171 A (09/07) (Bilingual)

Report Form Of Health Examination For School Entry

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