Private Physical Examination Form For School
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1
2PRIVATE PHYSICIAN’S REPORT OF PHYSICAL EXAMINATION OF A PUPIL OF SCHOOL AGE
DATE
20
NAME OF SCHOOL
GRADE
HOMEROOM
NAME OF CHILD
DATE OF BIRTH
SEX
Last
First
Middle
M F
ADDRESS
No. and Street
City or Post Office
Borough or Township
County
State
Zip Code
MEDICAL HISTORY IMMUNIZATIONS AND TESTS
Enter Month, Day, and Year each immunization was given
VACCINE
DOSES
BOOSTERS & DATES
Diphtheria and Tetanus
1
2
3
4
5
(Circle): DTaP, DTP, DT, TD
/
/
/
/
/
/
/
/
/
/
1
2
3
4
5
Polio (Circle): OPV, IPV
/
/
/
/
/
/
/
/
/
/
1
2
Measles, Mumps, Rubella
/
/
/
/
1
2
3
Hepatitis B
/
/
/
/
/
/
1
2
3
HIB
/
/
/
/
/
/
1
2
Varicella Disease or Lab
Varicella
/
/
/
/
Evidence
Date:
Other:
MEDICAL EXEMPTION
The physical condition of the above named child is such that immunization would endanger life or health
RELIGIOUS EXEMPTION
(Includes a strong moral or ethical conviction similar to a religious belief and requires a written
statement from the parent/guardian)
If Applicable:
Tuberculin Tests
Date Applied
Arm
Device
Antigen
Manufacturer
Signature
Date Read
Results (mm)
Signature
Follow-Up of significant tuberculin tests:
Parent/Guardian notified of significant findings on
.
Result of Diagnostic Studies:
.
Preventive Anti-Tuberculosis – Chemotherapy ordered.
No
Yes
Date
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