Department Of Education - Student'S Health Record
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1
2Department of Education
S
’
H
R
tudent
S
ealtH
ecoRd
Student Address Label
/
/
Name
Female
Preschool:
Entry Date
❑
(Last)
(First)
(Middle Initial)
/
/
Male
Elementary:
Entry Date
❑
/
/
Birthdate
Intermediate/Middle: Entry Date
Month
Day
Year
/
/
High:
Entry Date
Parent’s Name
(Mother/Legal Guardian)
(Father/Legal Guardian)
Allergies:
Please complete the following sections (CHECK IF YES)
M
S
edical
tatuS
Allergy (type)
Cancer/Leukemia
Hearing Problems
Hypertension
Seizures
Vision Problem
❑
❑
❑
❑
❑
❑
Asthma
Chronic Cough/Wheezing
Heart Disease
JRA Arthritis
Sickle Cell Anemia
❑
❑
❑
❑
❑
Behavioral Problems
Diabetes
Hemophilia
Rheumatic Heart
Skin Problems
❑
❑
❑
❑
❑
P
’
e
c
: n-n
; a-a
; c-c
; R-R
c
HySician
S
xaMination
ode
oRMal
bnoRMal
oRRected
eceiving
aRe
Varicella
Vision
Hearing
Immunity
Provider’s Stamp
Date
Provider’s Signature
Secondary to
or Printed Name
Disease (DATE)
R. L. R. L.
/
/
/
/
/
/
/
/
t
e
i
ubeRculoSiS
xaMination
(v
, d
g
: M
/d
/y
)
MMunizationS
accineS
ateS
iven
ontH
ay
eaR
M
t
(i
)
antoux
eSt
ntRadeRMal
Type
DTaP, DTP, DT,
Physician, APRN, PA, or Clinic
Date
Date
Results
Tdap or Td
Given
Read
(mm)
Date
/
/
/
/
/
/
/
/
/
/
/
/
Type
/
/
/
/
Polio
(IPV or OPV)
Date
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
c
x-R
Type
HeSt
ay
Hib (Haemophilus
influenzae type b )
Date
/
/
/
/
/
/
/
/
/
/
/
/
Date
Results
Location
Type
Pneumococcal
Conjugate
d
e
Date
/
/
/
/
/
/
/
/
/
/
/
/
ental
xaMination
Type
Dental Check-Up
Hepatitis B
/
/
Date
/
/
/
/
/
/
/
/
/
/
/
/
Date
MMR
Varicella
/
/
/
/
/
/
/
/
/
/
Hepatitis A
Date
/
/
/
/
Type
Other
*OFFICE USE ONLY (Rev. 2010)
Date
/
/
/
/
/
/
/
/
/
/
/
/
Type
Other
Date
/
/
/
/
/
/
/
/
/
/
/
/
Physician, APRN, PA or Clinic
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