MASSACHUSETTS SCHOOL HEALTH RECORD
PHYSICAL EXAM FORM, PRIVATE PHYSICIAN EXAMINATION
Tantasqua Regional Junior High School, 320 Brookfield Road, Fiskdale, MA
01518
Voice 508-347-7381, Fax 508-347-3994
Student Name _________________________________________________ Grade
__________
Date of Exam ______________________________ HT
____________ WT ____________
Gross Hearing-
Blood Pressure __________________
Vision-
Pulse
__________________________
Dental Screen - Needs Care ____, Adequate _____
Hct. or Hgb. _____________________
Urine __________________________
Estimate of Health -
Other Lab________________________
Significant illness or injury since last seen -
IMMUNIZATIONS - Give exact dates & circle DTP/DTaP/DT or OPV/IPV.
ENTERING 7TH GRADERS MUST HAVE - Td BOOSTER (IF 5 yrs. since last DPT),
MMR#2, HEPATITIS-B SERIES & one dose VARIVAX (2 doses if 13 yrs. or older)
OR doctor history of CHICKENPOX.
DTP/DTaP/DT- _______, _______, ________, ________, ________, Td _______,
________
OPV/IPV ----- _______, _______, ________, ________, ________, MMR _______, _______
HEP/B (3 Dose Series) #1 _______, #2 _______, #3 _______
OR
HEP/B (2 Dose Series) #1 _______, #2 _______ MANUFACTURER'S NAME
______________
HIB ------- #1 _______, #2 _______, #3 _______, #4 _______, #5 _______
VARIVAX - #1 ___, AGE __ #2 ___, VARICELLA TITER ___, OR CHICKENPOX
DIS ____
TB Test -- Type __________ Date ____________ Result
____________
Type __________
Date _____________ Result ____________
Type __________
Date _____________ Result ____________
Serious Allergy / Other -
Medication or treatment orders to be carried out at school -
Restrictions to sport/gym activity or modifications to school program -
Postural Screening -
RELEASE TO FAX IMMUNIZATIONS/PHYSICAL FORM SIGNED - YES ___ NO ___
_______________________________or _____________________________
Signature of Examining Physician
Signature of Nurse Practitioner
(DOCTOR STAMP ALSO REQUIRED)
Name / Address (please print) _____________________________ Phone
_____________
_________________________________________________
4/03/bb SCHOOL USE Date Received _______Sport Pass Given ______ Grade _____