Commonwealth Of Virginia School Entrance Health Form Page 4
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4Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT
A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry
into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at
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Student’s Name: _______________________________________________ Date of Birth: _____/_____/__________
Sex:
M
F
Physical Examination
Date of Assessment: _____/_____/_______
1 = Within normal
2 = Abnormal finding
3 = Referred for evaluation or treatment
Weight: ________lbs. Height: _______ ft. ______ in.
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2
3
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2
3
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2
3
Body Mass Index (BMI): ___________ BP____________
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HEENT
Neurological
Skin
Age / gender appropriate history completed
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Lungs
Abdomen
Genital
Anticipatory guidance provided
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Heart
Extremities
Urinary
TB Screening: □ No risk for TB infection identified
□ No symptoms compatible with active TB disease
□ Risk for TB infection or symptoms identified
TST/IGRA Result: □ Positive □ Negative
Test for TB Infection: TST IGRA Date:_______
TST Reading _____mm
CXR Date: __________ □ Normal □ Abnormal
CXR required if positive test for TB infection or TB symptoms.
EPSDT Screens Required for Head Start – include specific results and date:
Blood Lead:___________________________________________
Hct/Hgb ____________________________________________
Within normal
Concern identified:
Referred for Evaluation
Assessed for:
Assessment Method:
Emotional/Social
Problem Solving
Language/Communication
Fine Motor Skills
Gross Motor Skills
Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
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Unable to test – needs rescreen
1000
2000
4000
Referred to Audiologist/ENT
R
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Permanent Hearing Loss Previously identified:
___Left
___Right
L
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Hearing aid or other assistive device
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Screened by OAE (Otoacoustic Emissions):
Pass
Refer
With Corrective Lenses (check if yes)
Pass
Fail
Not tested
Stereopsis
Problem Identified: Referred for treatment
Distance
Both
R
L
Test used:
No Problem: Referred for prevention
20/
20/
20/
No Referral: Already receiving dental care
Pass
Referred to eye doctor
Unable to test – needs rescreen
Summary of Findings (check one):
□ Well child; no conditions identified of concern to school program activities
□ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________
_____________________________________________________________________________________________________________________________
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___ Allergy
food: _____________________
insect: _____________________
medicine: _____________________
other: _________________
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Type of allergic reaction:
anaphylaxis
local reaction
Response required:
none
epinephrine auto-injector
other: ________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
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___ Developmental Evaluation
Has IEP
Further evaluation needed for: ___________________________________________________________
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___ Medication. Child takes medicine for specific health condition(s).
Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________
Health Care Professional’s Certification
□ By checking this box, I certify with an electronic signature that all of
)
(Write legibly or stamp
the information entered above is accurate (enter name and date on signature and date lines below).
Name: _____________________________________
Signature: ________________________________________ Date: ____/_____/______
Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________
Phone: _______-_______-____________________ Fax: _______-_______-______________ Email: ______________________________________________
MCH 213G reviewed 03/2014
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