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COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health

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MCH 213 G revised 10/2010
1
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: _________________________________________________________________________________________________________________________
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 Mother or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Name of Father or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ 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 deafness
Attention-Deficit/Hyperactivity 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 tube, hospitalizations, oxygen support, hearing aid, 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:
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/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: ______________________________________________________________________Date: _______/________/ __________
Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________
Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______
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MCH 213 G revised 10/2010
2
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.
Certification of Immunization 11/06
Student’s Name: Date of Birth: |____|____|____|
Last First Middle Mo. Day Yr.
IMMUNIZATION
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
years of age)
1
2
3
4
5
*Tdap booster (6
th
grade entry)
1
*Poliomyelitis (IPV, OPV)
1
2
3
4
*Haemophilus influenzae Type b
(Hib conjugate)
*only for children <60 months of age
1
2
3
4
*Pneumococcal (PCV conjugate)
*only for children <2 years of age
1
2
3
4
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)
Merck adult formulation used
1
2
3
*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
Other
1
2
3
4
5
* Required vaccine
I certify that this child is ADEQUATELY 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 Regulations for the Immunization of School Children (Minimum requirements are listed in Section III).
Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____
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MCH 213 G revised 10/2010
3
Student’s Name: Date of Birth: |____ |_ ___|___ _|
Section II
Conditional Enrollment and Exemptions
Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.
Certification of Immunization 10/2010
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/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]
This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.
Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
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 CRE-1), which may be obtained at
any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).
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 requirements within the next 90 calendar days. Next
immunization due on __________________.
Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
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 of Virginia § 32.1-46(a)).
(requirements are subject to change.)
Section III
Requirements
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MCH 213 G revised 10/2010
4
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: _____/_____/__________ Sex: □ M □ F
Health Assessment
Date of Assessment: _____/_____/_______
Weight: ________lbs. Height: _______ ft. ______ in.
Body Mass Index (BMI): ___________ BP____________
Age / gender appropriate history completed
Anticipatory guidance provided
TB Risk Assessment: □ No Risk □ Positive/Referred
Mantoux results: __________________mm
Physical Examination
1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment
1
2
3
1
2
3
1
2
3
HEENT
□
□
□
Neurological
□
□
□
Skin
□
□
□
Lungs
□
□
□
Abdomen
□
□
□
Genital
□
□
□
Heart
□
□
□
Extremities
□
□
□
Urinary
□
□
□
EPSDT Screens Required for Head Start – include specific results and date:
Blood Lead:___________________________________________ Hct/Hgb ____________________________________________
Developmental
Screen
Assessed for:
Assessment Method:
Within normal
Concern identified:
Referred for Evaluation
Emotional/Social
Problem Solving
Language/Communication
Fine Motor Skills
Gross Motor Skills
Hearing
Screen
Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
1000
2000
4000
R
L
Screened by OAE (Otoacoustic Emissions): □ Pass □ Refer
□ Referred to Audiologist/ENT □ Unable to test – needs rescreen
□ Permanent Hearing Loss Previously identified: ___Left ___Right
□ Hearing aid or other assistive device
Vision
Screen
With Corrective Lenses (check if yes)
Stereopsis
Pass
Fail
Not tested
Distance
Both
R
L
Test used:
20/
20/
20/
Pass
Referred to eye doctor
Unable to test – needs rescreen
Dental
Screen
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 Personnel
Summary 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): _______________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________
Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epi pen □ other: _______________________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________
___ Medication. Child takes medicine for specific health condition(s). □ Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________
Health Care Professional’s Certification (Write legibly or stamp):
Name : _____________________________________ Signature: ________________________________________ Date: ____/_____/______
Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________
Phone: _______-_______-____________________ Fax: _______-_______-_____________________ Email: _________________________________________
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COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health

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Completed 25 January 2022

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