Student Health Record Form
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HOWELL TOWNSHIP PUBLIC SCHOOLS STUDENT HEALTH RECORD
Child’s Name:
Date:
Parent’s Name:
Phone:
Address:
D.O.B.:
Name of Family Physician:
Phone:
IMMUNIZATION RECORD (MONTH, DAY, YEAR AS REQUIRED BY LAW)
DISEASE
1st Dose
2nd Dose
3rd Dose
4th Dose
5th Dose
VACCINE TYPE
DATE
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
DIPTHERIA, TETANUS, PERTUSSIS
(DTaP) or any combination
*(If Td or DT, Indicate in corner box)
Tdap
Polio – Inactivated Polio Vaccine (IPV)
If oral vaccine, indicate (OPV) in corner box
MEASLES, MUMPS, RUBELLA (MMR)
Measles
Date
Titer:
MEASLES
Serology
Rubella
Date
Titer:
MUMPS
Serology
Mumps
Date
Titer:
RUBELLA
Serology
HAEMOPHLUS B (HIB)
HEPATITIS B
VARICELLA
PNEUMOCOCCAL CONJUGATE
MENINGOCOCCAL
HEPATITIS A
INFLUENZA VACCINE
OTHER
Tuberculin Test (Mantoux):
(as required)
Date Given:
Date Read:
Results:
Is child receiving any medication? __Yes __No
Name of Medication:
MEDICAL HISTORY
Asthma_____ Allergies______________ Chickenpox_____ Pneumonia_____ Operations________________
Major Injuries_____________ Lyme Disease_____ Mononucleosis_____ Encephalitis_____ Meningitis_____
Rheumatic Fever_____ Head Injury_____ Other_________________________ Diabetes_____ Seizure Disorder_____
Major Sensory Defect_____ Does child wear glasses?_____ Explain:____________________
PHYSICAL APPRAISAL
Height_______ Weight_______ B/P__________ Heart________ Eyes________ Ears_______ Lungs_______
Glands_____ Nose______ Throat______ Tonsils______ Thyroid______ Lymph Glands______ Hernia______
Abdomen______ Nutrition______ Scoliosis______________ (10 years and up)
Physician’s Comments:
Physician’s Signature:
Date of Physical Exam:
(stamps are not accepted)
Physician’s Name:
Phone:
(please print)
(Revised 10/14)
PHYSICIAN’S STAMP
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Parent category: Medical