Fillable Printable School Entrance Health Form - Virginia

School Entrance Health Form - Virginia

MCH 213G reviewed 03/2014

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 Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Name of Parent or Legal Guardian 2: ____________________________________________ 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, 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.  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: ______/_____/_______

MCH 213G 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.

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)

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

years of age)

*Tdap booster (6

grade entry)

*Poliomyelitis (IPV, 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

Date of Varicella Disease OR Serological Confirmation of Varicella

Immunity:

Hepatitis A Vaccine

Meningococcal Vaccine

Human Papillomavirus Vaccine

Other

* 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 (Reference Section III).

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____

MCH 213G reviewed 03/2014

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 03/2014

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

MCH 213G reviewed 03/2014

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

HEENT

□

Neurological

□

Skin

□

Lungs

□

Abdomen

□

Genital

□

Heart

□

Extremities

□

Urinary

□

TB Screening: □ 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: □ Positive □ Negative

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.

1000

2000

4000

 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

Test used:

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 □ 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: ______________________________________________