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:
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
is
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:
I
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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)
1
2
3
4
5
*Diphtheria, Tetanus (DT) or Td (given after 7
1
2
3
4
5
years of age)
*Tdap booster (6
th
grade entry)
1
*Poliomyelitis (!PV, OPV)
1
2
3
4
*Haemophilus influenzae Type b
1
2
3
4
(Hib conjugate)
*only for children <60 months of age
*Pneumococcal (PCV conjugate)
1
2
3
4
*only for children <60 months of age
Measles, Mumps, Rubella (MMR vaccine)
1
2
*Measles (Rubeola)
1
2
Serological Confirmation of Measles Immunity:
*Rubella
1
Serological Confirmation of Rubella Immunity:
*Mumps
1
2
*Hepatitis B Vaccine (HBV)
1
2
3
D
Merck adult formulation used
*Varicella Vaccine
1
2 Date of Varicella Disease OR Serological Confirmation of Varicella
Immunity:
Hepatitis A Vaccine
1
2
Meningococcal Vaccine
1
Human Papillomavirus Vaccine
1
2
3
Other
1
2
3
4
5
Other
1
2
3
4
5
I certify that this child is ADEQUATEL
y
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:
As
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
3
D With Corrective Lenses (check if yes)
Stereopsis D Pass D Fail D Not tested
= =
Distance
I Both
IR IL
Test used:
Q ~
._
~
.ta
b
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:
-_/
__
/
__
l
=
Within normal 2
=
Abnormal finding 3
=
Referred for evaluation or treatment
Weight: lbs.
Height: ___ ft. __ in.
I
2
3 l 2 3
I
2
3
....
Body Mass Index (BMI): BP
=
HEENT
Neurological
Skin~
D
D D
D
D D
D D D
Ei
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 D
..c:
.::::
TB Screening:
D
No risk for TB infection identified
D
No symptoms compatible with active TB disease
CIl
~
D
Risk for TB infection or symptoms identified
=:
Test for TB Infection: TST IGRA Date:
TST Reading __ mm
TSTIIGRA Result:
D
Positive
D
Negative
CXR required if positive test for TB infection or TB symptoms. CXRDate:
D
Normal
D
Abnormal
EPSDT Screens Required for Head Start - include specific results and date:
Blood Lead: HctlHgb
Assessedfor:
Assessment Method:
Within normal Concern identified:
Referredfor Evaluation
'i
Emotional/Social
....
=
Problem Solving
~
=
Ei ~
Q.~
Language/Communication
oS
b
~oo
~
Fine Motor Skills
~
Gross Motor Skills
D Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
gf=
I:
I
1000
I
2000
I
4000
I
D
Referred to AudiologistlENT
D
Unable to test - needs rescreen
._
~
..
~
D
Permanent Hearing Loss Previously identified: _Left _Right
CIl ..
~ OJ
=:00
D
Hearing aid or other assistive device
D Screened by OAE (Otoacoustic Emissions):
D
Pass
D
Refer
Summary of Findings (check one):
:li!
'il
D
Well child; no conditions identified of concern to school program activities
:.æ
=
D
Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):
U
=
~
Q
fil
"S
..
Q
~
_ Allergy
D
food:
D
insect:
D
medicine:
D
other:
..c:
~
'"
=
Type of allergic reaction:
D
anaphylaxis
D
local reaction Response required:
D
none
D
epinephrine auto-injector
D
other:
00
Q
....
'=
..
=
_Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
e:.-
t
.s
~
_ Restricted Activity Specify:
fil
=
=
....
_ Developmental Evaluation
D
Has lEP
D
Further evaluation needed for:
o
~
'=
0:1
..
'O
0:1
_ Medication. Child takes medicine for specific health condition(s).
D
Medication must be given and/or available at school.
=
¡.;¡
'"
..
Ei
o
_ Special Diet
Specify:
Ei
or
o
..
'"
0:1
_ Special Needs Specify:
~
U
Other Comments:
Health Care Professional's Certification (Write legibly or stamp)
D
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
4
click to sign
signature
click to edit