MASSACHUSETTS SCHOOL HEALTH
RECORD
Health
Care Provider’s Examination
Name
________________________________________ Male Female Date of
Birth:________
Medical History _____________________________________________________________________________
____________________________________________________________________________________________
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._______________________________________
______________________________________________ Date____________________________
Please print name of Examiner.
___________________________________________
Signature
of Examiner Circle: MD, DO, NP, PA