School Health Physical Form (Page 2 of 2) in pdf

School Health Physical Form Page 2

School Health Physical Form

Top Knowledge Healthcare Institute

19 East Fayette Street, Suite 401

Baltimore, MD 21202

Phone:410-528-1600|Fax:410-528-1663

Section C (REQUIRED): Print legibly in blue or black ink

Tuberculosis Skin Test-(TST) Must have been performed in the last 12 months

Placement Date:

Read Date:

Result: Attach copy of Lab Report

_________________

MM/DD/YYYY

TB Blood Tests- Must have been performed in the last 12 months.

QuantiFERON-TB Gold or T-Spot

Date:

Result: Attach copy of Lab Report

(Circle one)

_________________

MM/DD/YYYY

Chest X-ray-Required only if TST or TB Blood Tests were positive.

Date:

Normal or Abnormal

Result: Attach copy of Radiology Report

_________________

(Circle one)

MM/DD/YYYY

Section D (RECOMMENDED): Print legibly in blue or black ink. Students electing not to receive the

Hepatitis B Vaccination are required to sign the Hepatitis B waiver form.

Hepatitis B Vaccination- Must have been performed in the last 12 months

Dose 1:

Dose 2:

Dose 3:

_________________

MM/DD/YYYY

I have completely reviewed the information presented on this form and certify that it is

complete and accurate.

Name of Provider (title): ______________________________ Phone Number:________________

Address: ______________________________________________________________________

Signature of provider: ______________________________________ Date: _________________

School Health Physical Form Page 2