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