MASSACHUSETTS SCHOOL HEALTH RECORD

Health Care Provider’s Examination

Name ________________________________________  Male  Female    Date of Birth:___________________

Medical History _________________________________________________________________________________________

_______________________________________________________________________________________________________

Pertinent Family History

Current Health Issues

Y             N

            Allergies:  Please list:  Medications ______________________ Food _________________ Other ______________

      History of Anaphylaxis to ___________________ Epi-Penâ:   Yes   No

            Asthma:    Asthma Action Plan   Yes   No (Please attach)

            Diabetes:    Type I      Type II

             Seizure disorder:  ____________________________________________________________________________

             Other (Please specify) _________________________________________________________________________

Current Medications (if relevant to the student's health and safety)  Please circle those administered in school;  a separate medication order form is needed for each medication administered in school.

Physical Examination                                                                          Date of Examination:___________________________

Hgt: ________(_____%)  Wgt:_________(_____%)  BMI: _________(_____%)  BP: ________ 

(Check = Normal / If abnormal, please describe.)

 General ________________       Lungs __________________     Extremities _____________                          

  Skin __________________       Heart ___________________    Neurologic _____________      

  HEENT _______________         Abdomen _______________     Other __________________                       

  Dental/Oral ____________         Genitalia ________________

Screening:                            (Pass) (Fail)                                                                          (Pass) (Fail)                                                                        (Pass) (Fail)

              Vision: Right Eye                                   Hearing: Right Ear                            Postural  Screening:       

                             Left Eye                                                     Left Ear                            (Scoliosis/Kyphosis/Lordosis)

                            Stereopsis        

Laboratory Results:          Lead _______  Date _______________     Other____________________________________

The entire examination was normal:   

Targeted TB Skin Testing:  Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors):  Date of PPD: ____;  Results: ____mm.

Referred for evaluation to:  _______________________________________       Low risk (no PPD done)

This student has the following problems that may impact his/her educational experience:

 Vision                                 Hearing                             Speech/Language                          Fine/Gross Motor Deficit

  Emotional/Social             Behavior                           Other

Comments/Recommendations:_____________________________________________________________________

Y   N This student may participate fully in the school program, including physical education and competitive sports.  If no, please list restrictions:_____________________________________________________________________________________

 Y  N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System Certificate or other complete immunization record.