Health Inventory Form printable pdf download

Maryland Schools

Record of

Physical Examination

To Parents or Guardians:

In order for your child to enter a Maryland Public school for the first time, the following are

required:

A physical examination by a physician or certified nurse practitioner must be

completed within nine months prior to entering the public school system or within

six months after entering the system. A Physical Examination form designated by the

Maryland State Department of Education and the Department of Health and Mental

Hygiene shall be used to meet this requirement.

( )

Evidence of complete primary immunizations against certain childhood

communicable diseases is required for all students in preschool through the

twelfth grade. A Maryland Immunization Certification form for newly enrolling students

may be obtained from the local health department or from school personnel. The

immunization certification form (DHMH 896) or a printed or a computer generated

immunization record form and the required immunizations must be completed before a

child may attend school. This form can be found at:

Evidence of blood testing is required for all students who reside in a designated at

risk area when first entering Pre-kindergarten, Kindergarten, and 1

grade. The

blood-lead testing certificate (DHMH 4620) (or another written document signed by a

Health Care Practitioner) shall be used to meet this requirement. This form can be found

at:

620.pdf.

Exemptions from a physical examination and immunizations are permitted if they are contrary to

a students’ or family’s religious beliefs. Students may also be exempted from immunization

requirements if a physician/nurse practitioner or health department official certifies that there is

a medical reason not to receive a vaccine. Exemptions from Blood-Lead testing is permitted if it

is contrary to a families religious beliefs and practices. The Blood- lead certificate must be

signed by a Health Care Practitioner stating a questionnaire was done.

The health information on this form will be available only to those health and education

personnel who have a legitimate educational interest in your child.

Please complete Part I of this Physical Examination form. Part II must be completed by a

physician or nurse practitioner, or a copy of your child's physical examination must be

attached to this form.

If your child requires medication to be administered in school, you must have the

physician complete a medication administration form for each medication. This form can

be obtained at

9AA8-5529C5F4C749/3341/medicationform404.pdf. If you do not have access to a

physician or nurse practitioner or if your child requires a special individualized health

procedure, please contact the principal and/or school nurse in your child's school.

Maryland State Department of Health and Mental Hygiene

Maryland State Department of Education

Records Retention - This form must be retained in the school record until the student is age 21.

Maryland Schools -Record of Physical Examination Revised 12/04

Health Inventory Form

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