Health Form COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization Part I – HEALTH INFORMATION FORM State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child’s entry into school.Name of School: Current Grade: Student’s Name: First Middle Last Student’s Date of Birth: MM slash DD slash YYYY Sex: State or Country of Birth: Main Language Spoken: Student’s Address: City: State: Zip: Name of Parent or Legal Guardian 1: PhoneWork or Cell:Name of Parent or Legal Guardian 2: PhoneWork or Cell:Emergency Contact: PhoneWork or Cell:Allergies (food, insects, drugs, latex) Yes CommentsAllergies (seasonal) Yes CommentsAsthma or breathing problems Yes CommentsAttention-Deficit/Hyperactivity Disorder Yes CommentsBehavioral problems Yes CommentsDevelopmental problems Yes CommentsBladder problem Yes CommentsBleeding problem Yes CommentsBowel problem Yes CommentsCerebral Palsy Yes CommentsCystic fibrosis Yes CommentsDental problems Yes CommentsDiabetes Yes CommentsHead injury, concussions Yes CommentsHearing problems or deafness Yes CommentsHeart problems Yes CommentsLead poisoning Yes CommentsMuscle problems Yes CommentsSeizures Yes CommentsSickle Cell Disease (not trait) Yes CommentsSpeech problems Yes CommentsSpinal injury Yes CommentsSurgery Yes CommentsVision problems Yes CommentsDescribe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance, etc.):List all prescription, over-the-counter, and herbal medications your child takes regularly:Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No Please provide the following information:Pediatrician/primary care providerName PhoneDate of Last Appointment MM slash DD slash YYYY SpecialistName PhoneDate of Last Appointment MM slash DD slash YYYY DentistName PhoneDate of Last Appointment MM slash DD slash YYYY Case Worker (if applicable)Name PhoneDate of Last Appointment MM slash DD slash YYYY Child’s Health Insurance: None FAMIS Plus (Medicaid) FAMIS Private/Commercial/Employer sponsored I, do do not authorize my child’s health care provider and designated provider of health care in the school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record.Signature of Parent or Legal Guardian: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Signature of person completing this form: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Signature of Interpreter: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Part II - Certification of Immunization Section I To be completed by a physician or his designee, registered nurse, or health department official. See Section II for conditional enrollment and exemptions. A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box.Student’s Name: First Middle Last Date of Birth: MM slash DD slash YYYY IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN*Diphtheria, Tetanus, Pertussis (DTP, DTaP)12345*Diphtheria, Tetanus (DT) or Td (given after 7 years of age)12345*Tdap booster (6th grade entry)1*Poliomyelitis (IPV, OPV)1234*Haemophilus influenzae Type b (Hib conjugate) *only for children <60 months of age1234*Pneumococcal (PCV conjugate) *only for children <60 months of age1234Measles, Mumps, Rubella (MMR vaccine)12*Measles (Rubeola)12Serological Confirmation of Measles Immunity:*Rubella1Serological Confirmation of Rubella Immunity:*Mumps12*Hepatitis B Vaccine (HBV) q Merck adult formulation used123*Varicella Vaccine12Hepatitis A Vaccine12Meningococcal Vaccine1Human Papillomavirus Vaccine123Other12345Other12345Other12345I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in MINIMUM requirements for a child attending school, * Required vaccine care or preschool prescribed by Regulations for the Immunization of School State Board of Health’s.Children Signature of Medical Provider or Health Department Official: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Certification of Immunization 11/06Student’s Name: Date of Birth: MM slash DD slash YYYY Section III Requirements For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at https://www.vdh.virginia.gov/epidemiology/immunization Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)). (Requirements are subject to change.) Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth. Student’s Name: Date of Birth: MM slash DD slash YYYY Sex: M F Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth. Health AssessmentDate of Assessment MM slash DD slash YYYY Weight: .lbsHeight: ft.Height in.Body Mass Index (BMI): BP Age / gender appropriate history completed Anticipatory guidance provided Physical Examination 1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatmentHEENT 1 2 3 Neurological 1 2 3 Skin 1 2 3 Lungs 1 2 3 Abdomen 1 2 3 Genital 1 2 3 Heart 1 2 3 Extremities 1 2 3 Urinary 1 2 3 TB Screening: No risk for TB infection identified No symptoms compatible with active TB disease Risk for TB infection or symptoms identified Test for TB Infection: TST IGRA Date: MM slash DD slash YYYY TST Reading mmTST/IGRA Result: Positive Negative CXR required if positive test for TB infection or TB symptoms.CXR Date MM slash DD slash YYYY CXR Normal Abnormal EPSDT Screens Required for Head Start – include specific results and date:Blood Lead: Hct/Hgb Developmental ScreenAssessed for: Emotional/SocialAssessment Method:Within normalConcern identified:Referred for EvaluationAssessed for: Problem SolvingAssessment Method:Within normalConcern identified:Referred for EvaluationAssessed for: Language/CommunicationAssessment Method:Within normalConcern identified:Referred for EvaluationAssessed for: Fine Motor SkillsAssessment Method:Within normalConcern identified:Referred for EvaluationAssessed for: Gross Motor SkillsAssessment Method:Within normalConcern identified:Referred for EvaluationHearing ScreenScreened at 20dB: Indicate Pass (P) or Refer (R) in each box.R100020004000L100020004000Screened by OAE (Otoacoustic Emissions): Pass Refer Untitled Referred to Audiologist/ENT Permanent Hearing Loss Previously identified: Left Right Hearing aid or other assistive device Unable to test – needs rescreen Vision Screen With Corrective Lenses (check if yes)Stereopsis Pass Fail Not tested Distance Both R L Test used: Untitled Pass Referred to eye doctor Unable to test – needs rescreen Dental ScreenUntitled Problem Identified: Referred for treatment No Problem: Referred for prevention No Referral: Already receiving dental care Recommendations to (Pre) School , Child Care, or Early Intervention PersonnelSummary of Findings (check one): Well child; no conditions identified of concern to school program activities Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): (complete sections below and/or explain here): Conditions Allergy Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc) Restricted Activity Developmental Evaluation Medication. Child takes medicine for specific health condition(s). Special Diet Special Needs Allergy Food Insect Medicine Other Type of allergic reaction: Anaphylaxis Local reaction Response required: None Epinephrine auto-injector Other Developmental Evaluation Choices Has IEP Further evaluation needed for: Medication Choice Medication must be given and/or available at school. Needed for Other Specify Specify Specify Other Comments:Health Care Professional’s Certification (Write legibly or stamp) By checking this box, I certify with an electronic signature that all of the information entered above is accurate (enter name and date on signature and date lines below). Name Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Practice/Clinic Name: Address: PhoneFax:Email: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Download Here
