Fillable Student Record Card 6 (Montgomery Schools)

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Student Record Card 6 (Montgomery Schools)

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MARYLAND SCHOOLS RECORD OF PHYSICAL EXAMINATION
To Parents or Guardians:
In order for your child to enter a Maryland public school for the first time, the following are required:
• A physical examination by an authorized health care provider must be completed within
nine months prior to entering the public school system or within six months after
entering the system. A physical examination form designated by the Maryland State Department
of Education and the Maryland Department of Health must be used to meet this requirement.
• Evidence of complete primary immunizations against certain childhood communicable
diseases is required for all students in preschool through the twelfth grade. A Maryland
Immunization Certification form for newly enrolling students may be obtained from the local
Department of Health and Human Services or from school personnel. The form and the required
immunizations must be completed before a child may attend school. (Form MDH 896).
• Evidence of blood lead testing is required for all students who reside in a designated
at risk area or who are enrolled in Medicaid when first entering Prekindergarten,
Kindergarten, and Grade 1, and for ALL children born on or after January 1, 2015.
The Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate (DHMH
4620) (or another written document signed by an authorized health care provider) shall be used
to meet this requirement.
Exemptions from immunizations are permitted if they are contrary to a student’s or family's religious
beliefs, and require parent/guardian signature on MDH Form 896. Students also may be exempted
from immunization requirements if an authorized health care provider certifies that there is a medical
reason not to receive a vaccine. Exemptions from blood lead testing is permitted if it is contrary to
a family’s religious beliefs and practices. The Blood Lead Testing Certificate must be signed by an
authorized health care provider stating a questionnaire was done.
The health information on this form will be available only to those health and education personnel
who have a legitimate educational interest in your child.
In order to assist your child in gaining the most from their educational experience, please complete Part
I of this Physical Examination form. Part II must be completed by an authorized health care provider,
or attach a copy of your child’s physical examination to this form. If your child requires medication
and or a treatment to be administered in school, you must have the authorized health care provider
complete a medication and or treatment administration form for each medication and or treatment to
be administered. These forms can be obtained from your child’s school or online from the Montgomery
County Public Schools (MCPS) website at www.montgomeryschoolsmd.org: MCPS Form 525-12, Authorization
to Provide Medically Prescribed Treatment, Release and Indemnification Agreement, MCPS Form 525-13,
Authorization to Administer Prescribed Medication, Release and Indemnification Agreement, MCPS Form
525-14, Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and
Indemnification Agreement for Epinephrine Auto Injector. If you do not have access to an authorized
health care provider or if your child requires a special individualized health procedure, please contact
the principal and/or school nurse in your child’s school.
Please complete this Physical Examination form and
return it to your child’s school as quickly as possible.
Student Record Card 6
Maryland State Department of Education (MSDE)
Maryland Department of Health (MDH)
MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS)
Rockville, Maryland
MCPS Form SR-6
January 2020
Page 1 of 4
PART 1 HEALTH ASSESSMENT
To be completed by parent/guardian
MCPS ID#
Student’s Name
(Last, First, Middle)
Birthdate
(Mo., Day, Yr.)
Name of School Grade
(Preferred Name)
Address (Number, Street, City, State, Zip) Phone No.
Parent/Guardian Names
Where do you usually take your child for routine medical care? Phone No.
Name: Address:
When was the last time your child had a physical exam? Month Year
When was the last time your child had a dental exam? Month Year
Where do you usually take your child for dental care? Phone No.
Name: Address:
ASSESSMENT OF STUDENT HEALTH
To the best of your knowledge, does your child have any of the following? Please check yes or no below.
Yes No Comments
Anaphylaxis or severe allergic reactions
Allergies (Food, Insects, Medications, Latex)
Allergies (Seasonal)
Asthma or Breathing Problems
Behavioral or Emotional Problems
Birth Defects
Bleeding Problems
Cerebral Palsy
Dental Problems
Diabetes
Ear Problem or Deafness
Eating Problems
Eye or Vision Problems
Head Injury
Heart Problems
Hospitalization (When, Where, Why)
Lead Poisoning/Exposure
Learning problems/disabilities
Limits on Physical Activity
Meningitis
Prematurity
Problem with Bladder
Problem with Bowels
Problem with Coughing
Seizures
Sickle Cell Disease
Speech Problems
Surgery
Other
Does your child take any medication? □ No □ Yes
If yes, name(s) of medications: _______________________________________________________________________________________________________
Will your child require any medication to be administered in school? □ No □ Yes
If yes, name(s) of medications: _______________________________________________________________________________________________________
Will your child require any emergency medications (epinephrine auto-injectors, inhalers, glucagon, Diastat, nebulized medication, etc.) to be adminis-
tered in school? □ No □ Yes If yes, please list _______________________________________________________________________________________
Will your child require any special treatments (G-tube feedings, catheterizations, etc.) to be administered in school? □ No □ Yes
If yes, please list
_____________________________________________________________________________________________________________________
I agree that by typing my name and today’s date below, and submitting this form by electronic mail, I am intending that the below constitutes and is the equivalent to my personal signature.
Parent/Guardian Signature Date
MCPS Form SR-6 • Page 2 of 4
PART II SCHOOL HEALTH ASSESSMENT
To be completed ONLY by authorized health care provider
MCPS ID#
Student's Name
(Last, First, Middle)
Birthdate
(Mo., Day, Yr.)
Name of School Grade
(Preferred Name)
1. Does the child have a diagnosed medical condition? □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
2. Does the child have a health condition which may require EMERGENCY ACTION while at school? (e.g., seizure, severe allergic reaction/anaphylaxis
to food or insect sting, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE. Additionally, please work
with the school nurse to develop an emergency plan. □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
3. Are there any abnormal findings on evaluation of concern? □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
EVALUATION FINDINGS/CONCERNS
PHYSICAL EXAM WNL ABNL
Area of
Concern
HEALTH AREA OF CONCERN Yes No
Head Attention Deficit/Hyperactivity
Eyes Behavior/Adjustment
ENT Development
Dental Hearing
Respiratory Immunodeficiency
Cardiac Lead Exposure/Elevated Lead
GI Learning Disabilities/Problems
GU Mobility
Musculoskeletal/Orthopedic Nutrition
Neurological Physical Illness/Impairment
Skin Psychosocial
Endocrine Speech/Language
Psychosocial Vision
Other
REMARKS: (Please explain any abnormal findings/health concerns.)
4. RECORD OF IMMUNIZATIONS: MDH 896 is required to be completed and attached by an authorized health care provider or a computer
generated immunization record must be provided.
5. Is the child on medication? If yes, indicate medication and diagnosis. □ No □ Yes
__________________________________________________________________________________________________________________________________
(MCPS Form 525-13, Authorization to Administer Prescribed Medication, Release and Indemnification Agreement and/or MCPS Form 525-14, Emer-
gency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and Indemnification Agreement for Epinephrine Auto Injector,
must be completed for medication administration in school).
6. Will the child require medically provided treatments, such as urinary catheterization, tracheostomy, gastrostomy feedings, and oral suctioning?
□ No □ Yes If yes, MCPS Form 525-12, Authorization to Provide Medically Prescribed Treatment, Release and Indemnification Agreement, must be
completed.
7. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. □ No □ Yes
MCPS Form 345-22 may be completed.
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
MCPS Form SR-6 • Page 3 of 4
PART II SCHOOL HEALTH ASSESSMENT (continued)
To be completed ONLY by authorized health care provider
8. Screenings Results/Date Taken Comments
Tuberculin Test (PPD, QFT, Questionnaire)
Blood Pressure/Heart Rate
Height
Weight
BMI %tile
Blood Lead Testing (DHMH 4620)
Hemoglobin/Hematocrit
(Student Name)
________________________________________________________________________ has had a complete physical examination and has:
□ No evident problem that may affect learning or full school participation □ Problems noted above
Additional Comments:
Name of Authorized Health Care Provider (Type or Print) Phone No. Authorized Health Care Provider Signature Date
MCPS Form SR-6 • Page 4 of 4
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Completed 20 March 2021

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