Form Mch 213g - School Entrance Health Form

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COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part I – HEALTH INFORMATION FORM

State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public

kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the

form. This form must be completed no longer than one year before your child’s entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _______________________

Student’s Name: _________________________________________________________________________________________________________________________

Last

First

Middle

Student’s Date of Birth: _____/_____/_______

Sex: _______

State or Country of Birth: ________________________ Main Language Spoken: ______________

Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________

Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Condition

Yes

Comments

Condition

Yes

Comments

Allergies (food, insects, drugs, latex)

Diabetes

Allergies (seasonal)

Head injury, concussions

Asthma or breathing problems

Hearing problems or deafness

Attention-Deficit/Hyperactivity Disorder

Heart problems

Behavioral problems

Lead poisoning

Developmental problems

Muscle problems

Bladder problem

Seizures

Bleeding problem

Sickle Cell Disease (not trait)

Bowel problem

Speech problems

Cerebral Palsy

Spinal injury

Cystic fibrosis

Surgery

Dental problems

Vision problems

Describe any other important health-related information about your child (for example; feeding tube,

hospitalizations,

oxygen support, hearing aid, dental appliance,

etc.):__________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

List all prescription, over-the-counter, and herbal medications your child takes regularly:

_______________________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with the school nurse or other school authority.

Yes

Please provide the following information:

Name

Phone

Date of Last Appointment

Pediatrician/primary care provider

Specialist

Dentist

Case Worker (if applicable)

Child’s Health Insurance: ____ None

____ FAMIS Plus (Medicaid)

_____ FAMIS

_____ Private/Commercial/Employer sponsored

I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the

school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you

withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record,

documentation of the disclosure is maintained in your child’s health or scholastic record.

Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

/_____/_______

Signature of Interpreter: __________________________________________________________________________________Date: ______

MCH 213G reviewed 03/2014