MCH213G reviewed 10/2020
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
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
Tuberculosis Screening
Check the box that applies:
□ 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:_______ __ TST Reading____ mm TST/IGRA Result: □ Negative □ Positive
CXR required if positive test for TB infection or TB symptoms. CXR Date:___________ □ Normal □ Abnormal
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.
Screened by OAE (Otoacoustic Emissions):
□ Pass □ Referred
1000 2000 4000
R
L
□ Referred to Audiologist/ENT □ Unable to test – needs rescreen
□ Permanent Hearing Loss Previously identified: □
Left
□ Right
□ Hearing aid or another assistive device
Vision Screen
□ With Corrective Lenses (Check if yes)
□ Pass □ Referred to eye doctor □ Unable to test-needs rescreen
Stereopsis □ Pass □ Fail □ Not tested
Distance
Both R L Test used:
20/ 20/ 20/
Dental
Screen
□ Problems Identified: Referred for Treatment
□ No Problem: Referred for prevention
□ No Referral: Already receiving dental care
□ Unable to perform
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 □ epinephrine auto-injector □ 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) □ 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:__________________________________
MCH213G reviewed 10/2020
