Report Of Health Examination Form

State of California - Health and Welfare Agency

Department of Health Services

Primary Care and Family Health Division

Children's Medical Services Branch

REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY

Child Health and Disability Prevention (CHDP) Prog.

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

BIRTHDATE: Month/Day/Year

ADDRESS: Number/Street

City, State

Zip Code

School

PART II TO BE FILLED OUT BY HEALTH EXAMINER

HEALTH EXAMINATION

IMMUNIZATION RECORD

Note: All tests and evaluations except the blood lead test

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

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

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

REQUIRED TESTS/EVALUATIONS

DATE

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

Nutritional Assessment

(diphtheria, tetanus, & (acellular) pertussis)

OR

Developmental Assessment

(tetanus & diphtheria only)

Vision Screening

MMR

Audiometric (hearing) Screening

(measles, mumps, and rubella)

Tuberculin Test (MANTOUX)

SEE BELOW

HIB MENINGITIS

(Haemophilus Influenza B)

Blood Test (for anemia)

(Required for child care/preschool only)

Urine Test

Blood Lead Test

HEPATITIS B

Other

VARICELLA

(Chickenpox)

MANTOUX TB SKIN TEST:

Date Given:__________

Date Read:_________

Read By:___________

Induration: _______mm _______neg. _______pos.

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.

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.

Examination shows no condition of concern to school program activities.

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

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 and office stamp 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.

PM 171 A (6/98) : 4/26/04 : IUSD intranet : Health Services : lm