MASSACHUSETTS SCHOOL HEALTH RECORD

Health Care Provider’s Examination

 

Name _______________________________________   o Male  o Female    Date of Birth _____________________

Medical History__________________________________________________________________________________

________________________________________________________________________________________________

Pertinent Family History

_______________________________________________________________________________________________

Current Health Issues

Y             N

o            o      Allergies: Please list:  Medications __________________ Food ______________ Other ___________

                          History of Anaphylaxis to _______________________ Epi-Penâ: o Yes  o  No

o            o      Asthma:  Asthma Action Plan  o Yes  o  No (Please attach)

o            o      Diabetes:   o Type I    o  Type II

o            o      Seizure Disorder: ___________________________________________________________________

o            o      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.)

                o General _____________                    o Lungs ___________           o Extremities ___________

                o Skin ________________                   o Heart ____________         o Neurologic ___________

                o HEENT _____________                   o Abdomen _________         o Other _______________

                o Dental/Oral __________                    o Genitalia __________

Screening:                             Pass   Fail                                                 Pass   Fail                                                 Pass  Fail

                Vision:  Right Eye   o      o                  Hearing:  Right Ear  o      o                  Postural Screening: o     o

                              Left Eye     o      o                                  Left Ear    o      o                (Scoliosis/Kyphosis/Lordosis)

                            Stereopsis     o      o

Laboratory Results:    o Lead ___________ Date __________   o Other __________________________________

The entire examination was normal:  o

Targeted TB Skin Testing:  o 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: __________________________________    o Low risk (no PPD done)

________________________________________________________________________________________________

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

o Vision                                                 o Hearing                               o Speech/Language                o Fine/Gross Motor Deficit

o Emotional/Social o Behavior             o Other
Comments/ Recommendations: ______________________________________________________________________

________________________________________________________________________________________________

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

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

 

__________________________________________ _________          _______________________________________

Signature of Examiner   Circle: MD, DO, NP, PA      Date                      Please print name of Examiner

 

____________________________________________________

Group Practice

 

______________________________________________________________________________________________

Address                                   City                                         State                                        Zip Code

 

Please attach additional information as needed for the health and safety of the student.                MDPH  11/29/04