
School Entry Health Exam
Page 2 of 2
Name of Child (Last, First, Middle) Birth Date
PART II
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MEDICAL EVALUATION
To be completed and signed by the Health Care Provider ONLY:
The child named above has had a complete history and physical exam on the following date:
(Exam must be within one year of enrollment)
Month Day Year
Screening Results:
Height: Weight: BMI%: B/P: Hct/Hgb: Lead: Urinalysis:
DH3040-CHP-07/2013
Vision - Without Glasses
Right 20/_____ Left 20/_____
Hearing – Right Passed Failed Referred
Passed
Failed
Right 20/_____ Left 20/_____
Vision - With Glasses
Referred
Hearing – Left Passed Failed Referred
Gross dental (teeth and gums) Normal Abnormal Refer/Tx:
Head/scalp/skin
Normal Abnormal Refer/Tx:
Eyes/Ears/Nose/Throat Normal Abnormal Refer/Tx:
Chest/Lungs/Heart Normal Abnormal Refer/Tx:
Abdomen Normal Abnormal Refer/Tx:
Postural assessment Normal Abnormal Refer/Tx:
(Please review Targeted Testing Guidelines listed below.)
TB risk assessment done
This child has the following problems that may impact the educational experience:
Vision Hearing Speech/Language Physical Social/Behavioral Cognitive
Specify:
This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below.
(This form will be stored in the child’s Cumulative Health Folder and may be accessed by both school and health personnel.)
Recommendations (Attach additional sheet if necessary):
(Please Check One)
This child may participate fully in school activities including physical education.
This child may participate in school activities including physical education with the following restriction/adaptation.
(Specify reason and restriction)
Signature/Title of Health Care Provider Date Address (Please print or stamp)
⌦
___/___/___
Name (Please print or stamp)
Tuberculosis Targeted Testing Guidelines for Health Care Providers
Tuberculosis Infection Risk:
Review the following risks and administer a Mantoux TB skin test if child is in one or more categories. The TB test is administered confidentially as
part of the health examination. Do not record administration of any TB test or related information on this form.
• Recent immigrant (< 5 years), frequent visitor to TB endemic areas
• Close contact to active TB case
• Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user
• HIV+ or have other medical conditions that increase the risk to progress from infection to disease, e.g., chronic renal failure,
diabetes, hematologic or any other malignancy, weight loss > 10% of ideal body weight, on immunosuppressive medications
Active TB Disease Risk:
• Does the child exhibit signs/symptoms of tuberculosis (e.g. cough for three weeks or longer, weight loss, loss of appetite)?
•
If symptoms are present, work-up or refer for TB disease evaluation.