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COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part

I - HEALTH INFORMA nON 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: _

Srudem'sName:

~------------------------_=~----------------------------~~~------------ _

Last First Middle

Student's Date of Birth: / /___ Sex: State or Country of Birth: Main Language Spoken: _

Student's Address: City: State: Zip: _

Name of Parent or Legal Guardian 1: Phone: Work or Cell: _

Name of Parent or Legal Guardian 2: _

Emergency Contact: Phone: _

Phone: __

Work or Cell:

Condition Yes Comments Condition

Yes Comments

Allergies (food, insects, drugs, latex)

Diabetes

Allergies (seasonal)

Head injury, concussions

Asthma or breathing problems Hearing problems or deafuess

Attention-DeficitlHyperactivity Disorder Heart problems

Behavioral problems Lead poisoning

Developmental problems Muscle problems

Bladder problem

Seizures

Bleeding problem

Sickle Cell Disease (not trait)

Bowel problem Speech problems

Cerebral Palsy Spinal injury

Cystic fibrosis Surgery

Dental problems

Vision problems

Describe any other important health-related information about your child (for example; feeding rube, 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. D Yes D No

Please provide the following information:

Name Phone Date of Last Appointment

Pediatrician/primary care provider

Specialist

Dentist

Case Worker (if applicable)

Child's Health Insurance: None

___ FAMIS Plus (Medicaid)

FAMIS ____ Private/CommerciallEmployer sponsored

Signature of Parent or Legal Guardian: .Date: / ---' _

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 authonzaüon at any time by contacting your child's school. When information

releasedfrom your child's record,

documentation of the disclosure is maintained in yOllr child's health or scholastic record.

Signature of person completing this form: ~Date: / ___' _

Signature of Interpreter: .Date:

/_--

MCH 213G reviewed 03/2014

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MCH

2130

reviewed

03/2014

COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

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:

Date ofBirth:

1_1_1_1

Last

First

Middle Mo.

Dav Yr.

IMMUNIZA TJON

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

*Diphtheria, Tetanus, Pertussis (DTP, DTaP)

*Diphtheria, Tetanus (DT) or Td (given after 7

years of age)

*Tdap booster (6

grade entry)

*Poliomyelitis (!PV, OPV)

*Haemophilus influenzae Type b

(Hib conjugate)

*only for children <60 months of age

*Pneumococcal (PCV conjugate)

*only for children <60 months of age

Measles, Mumps, Rubella (MMR vaccine)

*Measles (Rubeola)

Serological Confirmation of Measles Immunity:

*Rubella

Serological Confirmation of Rubella Immunity:

*Mumps

*Hepatitis B Vaccine (HBV)

Merck adult formulation used

*Varicella Vaccine

2 Date of Varicella Disease OR Serological Confirmation of Varicella

Immunity:

Hepatitis A Vaccine

Meningococcal Vaccine

Human Papillomavirus Vaccine

Other

I certify that this child is ADEQUATEL

OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child

care or preschool prescribed by the State Board of Health's

Regulationsfor the Immunization of School Children

(Reference Section III).

Signature of Medical Provider or Health Department Official:

Date

(Mo.,Day,Yr.):_/_/_

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Section III

Requirements

Student's Name: .Dateof Birth:

1_1_

_l_J

Section II

Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

MEDICAL EXEMPTION:

specified in the

Code of Virginia §

22.1-271.2, C

(ii),

I certify that administration of the vaccine(s) designated below would be

detrimental to this student's health. The vaccine(s) is (are) specifically contraindicated because (please specify):

DTP/DTaPffdap:[_]; DT/Td:[_]; OPV/IPV:[_]; Hib:[_]; Pneum:[_]; Measles:[_]; Rubella:[_l; Mumps:[_]; HBV:[_]; Varicella:L_l

This contraindication is permanent:

l_],

or temporary [_] and expected to preclude immunizations until: Date

(Mo., Day, Yr.):

I_I_I_I.

Signature of Medical Provider or HeaIth Department Official: Date

(Mo.,

Day,

Yr.):I_I_I_1

RELIGIOUS EXEMPTION: The

Code of Virginia

allows a child an exemption from receiving immunizations required for school attendance if the student or the

student's parent/guardian submits an affidavit to the school's admitting official stating that the administration of immunizing agents conflicts with the student's religious

tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form eRE-I), which may be obtained at

any local health department, school division superintendent's office or local department ofsocial services. Ref.

Code of Virginia §

22.1-271.2, e (i),

Signature of Medical Provider or Health Department Official: Date

(Mo., Day,

Yr.):I_I_I_1

CONDITIONAL ENROLLMENT: As specified in the

Code of Virginia

22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines

required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requi rements within the next 90 calendar days. Next

immunization due on .

For Minimum Immunization Requirements for Entry into School and

Day Care, consult the Division of Immunization web site at

http://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 a/Virginia § 32.1-46(a».

(Requirements are subject to change.)

Certification of Immunization 03/2014

MeH 213G reviewed 03/2014

D With Corrective Lenses (check if yes)

Stereopsis D Pass D Fail D Not tested

= =

Distance

I Both

IR IL

Test used:

Q ~

.ta

I 20/ I 20/ I 20/

>00

DPass D Referred to eye doctor D Unable to test - needs rescreen

D Problem Identified: Referred for treatment

D No Problem: Referred for prevention

D No Referral: Already receiving dental care

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.orglschoolhealth.

Student's Name· Date of Birth: / / Sex: D M D F

Physical Examination

Date of Assessment:

-_/

Within normal 2

Abnormal finding 3

Referred for evaluation or treatment

Weight: lbs.

Height: ___ ft. __ in.

3 l 2 3

....

Body Mass Index (BMI): BP

HEENT

Neurological

Skin~

D D

D D D

D Age / gender appropriate history completed

fil

Lungs

Abdomen

Genital

fil

D D D D D D D

D D

fil

D Anticipatory guidance provided

fil

Heart

D D D

Extremities

D D D

Urinary

D D

..c:

.::::

TB Screening:

No risk for TB infection identified

No symptoms compatible with active TB disease

CIl

Risk for TB infection or symptoms identified

Test for TB Infection: TST IGRA Date:

TST Reading __ mm

TSTIIGRA Result:

Positive

Negative

CXR required if positive test for TB infection or TB symptoms. CXRDate:

Normal

Abnormal

EPSDT Screens Required for Head Start - include specific results and date:

Blood Lead: HctlHgb

Assessedfor:

Assessment Method:

Within normal Concern identified:

Referredfor Evaluation

Emotional/Social

....

Problem Solving

Ei ~

Q.~

Language/Communication

~oo

Fine Motor Skills

Gross Motor Skills

D Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

gf=

1000

2000

4000

Referred to AudiologistlENT

Unable to test - needs rescreen

Permanent Hearing Loss Previously identified: _Left _Right

CIl ..

~ OJ

=:00

Hearing aid or other assistive device

D Screened by OAE (Otoacoustic Emissions):

Pass

Refer

Summary of Findings (check one):

:li!

'il

Well child; no conditions identified of concern to school program activities

:.æ

Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):

fil

_ Allergy

food:

insect:

medicine:

other:

..c:

Type of allergic reaction:

anaphylaxis

local reaction Response required:

none

epinephrine auto-injector

other:

....

_Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)

e:.-

_ Restricted Activity Specify:

fil

....

_ Developmental Evaluation

Has lEP

Further evaluation needed for:

0:1

_ Medication. Child takes medicine for specific health condition(s).

Medication must be given and/or available at school.

¡.;¡

_ Special Diet

Specify:

0:1

_ Special Needs 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: Date:

/_-

Practice/Clinic Name: Address:

Phone:

Fax:

Email:

-------

------

MCH 213G reviewed 03/2014

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