Council Rock School District Bucks County Pennsylvania ... Exam Form.pdf · Bucks County...
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Council Rock School District Bucks County Pennsylvania PRIVATE PHYSICIAN'S REPORT OF PHYSICAL EXAMINATION OF A PUPIL OF SCHOOL AGE DATE 20 _ NAME OF SCHOOL _ GRADE HOMEROOM _ NAME OF CHILD DATE OF BIRTH SEX MF Last First Middle ADDRESS No. and Street City or Post Office Borough or Township County State Zip Code MEDICAL HISTORY IMMUNIZATIONS AND TESTS Enter month, day & year each immunization was given VACCINE DOSES BOOSTERS & OATES Diphtheria and Tetanus 1 I I 2 I I 3 I I 4 I I 5 I I I Tdap7~gr 2011-12 (circle): DTaP, DTP, DT, TO (newrequirement) I I Polio (circle): OPV, IPV 1 I I 2 I I 3 I I 4 I I 5 I I MMR 1 s1 dose after 1 yr of age 1 I I 2 I I Measles 1st dose after 1 yr of age 1 I I 2 I I Mumps 1st dose after 1 yr of age 1 I I 2 I I (new requirement 2011) Rubella after 1 yr of age 1 I I Hepatitis S 1 I I 2 I I 3 I I Hepatitis A 1 I I 2 I I 3 I I HIS 1 I I 2 I I 3 I I Varicella I I 2 I I Varicella Disease or Lab Evidence 1 Date: 12011-2012 newrequirement) Entering 7U1 grade 2011-12 Meningococcal Conjugate (MCV) 1 I I (2011-2012 new requirement) Other 1 I I 2 I I 3 I I o MEDICAL EXEMPTION The physical condition of the above named child is such that immunization would endanger life or health. o RELIGIOUS EXEMPTION A strong moral or ethical conviction similar to a religious belief and requires a written statement from the parent or guardian. If Applicable: Tuberculin Tests Date Applied Arm Device Antigen Manufacturer Signature Date Read Results (mm) Signature Follow-Up of significant tuberculin tests: Parent/Guardian notified of significant findings on (Date) Result of Diagnostic Studies: (Date) Preventive Anti-Tuberculosis - Chemotherapy ordered: NO YES (Date) 00 (H511.336) (10/10)
Transcript of Council Rock School District Bucks County Pennsylvania ... Exam Form.pdf · Bucks County...
Council Rock School DistrictBucks County Pennsylvania
PRIVATE PHYSICIAN'S REPORT OFPHYSICAL EXAMINATION OF A PUPIL OF SCHOOL AGE
DATE 20 _
NAME OF SCHOOL _ GRADE HOMEROOM _
NAME OF CHILD DATE OF BIRTH SEX
M FLast First Middle
ADDRESS
No. and Street City or Post Office Borough or Township County State Zip Code
MEDICAL HISTORYIMMUNIZATIONS AND TESTS
Enter month, day & year each immunization was givenVACCINE DOSES BOOSTERS & OATES
Diphtheria and Tetanus 1 I I 2 I I 3 I I 4 I I 5 I II Tdap7~gr 2011-12
(circle): DTaP, DTP, DT, TO (newrequirement)I I
Polio (circle): OPV, IPV1 I I 2 I I 3 I I 4 I I 5 I I
MMR 1s1 dose after 1 yr of age1 I I 2 I I
Measles 1st dose after 1 yr of age1 I I 2 I I
Mumps 1st dose after 1 yr of age1 I I 2 I I (new requirement 2011)
Rubella after 1 yr of age1 I I
Hepatitis S 1 I I 2 I I 3 I IHepatitis A
1 I I 2 I I 3 I IHIS 1 I I 2 I I 3 I IVaricella I I 2 I I
Varicella Disease or Lab Evidence1 Date:12011-2012 newrequirement)
Entering 7U1 grade 2011-12 Meningococcal Conjugate (MCV)1 I I (2011-2012 new requirement)
Other 1 I I 2 I I 3 I I
o MEDICAL EXEMPTION The physical condition of the above named child is such that immunization would endanger life or health.
o RELIGIOUS EXEMPTION A strong moral or ethical conviction similar to a religious belief and requires a written statement from the parent or guardian.
If Applicable:
Tuberculin Tests Date Applied Arm Device Antigen Manufacturer Signature
Date Read Results (mm) Signature
Follow-Up of significant tuberculin tests:Parent/Guardian notified of significant findings on (Date)Result of Diagnostic Studies: (Date)Preventive Anti-Tuberculosis - Chemotherapy ordered: NO YES (Date)
00 (H511.336) (10/10)
AllergiesAsthmaCardiacChemical DependencyDrugsAlcohol
Diabetes MellitusGastrointestinal DisorderHearing DisorderHypertension •.Neuromuscular DisorderOrthopedic ConditionRespiratory ItlnessSeizure DisorderSkin DisorderVision DisorderOther (Specify)
YesoooooonL.Joooooooooo
Significant Medical Conditions C-J)No If Yes, Explainooooooooooooooooo
Are there any special medical problems or chronic diseases which require restriction of activity, medication or whichmight affect his/her education? If so, specify _
Report of Physical Examination 0)
Normal Abnormal Not Examined Comments
• Height (inches)
• Weight (pounds) BMI
• Pulse ( )
• Blood Pressure /
• Hair/Scalp
• Skin
• EyesNision
• Ears/Hearing
• Nose and Throat
• Teeth and Gingiva
• Lymph Glands
• Heart - Murmur, etc.
• Lung - Adventitious Findings,
• Abdomen
• Genitourinary
• Neuromuscular System
• Extremities
• Spine (Presence of Scoliosis)
Date of Examination
Signature of Examiner Print Name of Examiner
Telephone NumberAddress
