Form Meh-1 - Report Of Physical Examination
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1THE SCHOOL DISTRICT OF PHILADELPHIA
SCHOOL HEALTH SERVICES
REPORT OF PHYSICAL EXAMINATION
Name of Student
Date of Birth
Student ID #
Grade
Name of School
Room/Section/Book
Date Issued
TO THE CARE PROVIDER (Please complete all items)
Pennsylvania law requires that students attending school in the state be immunized and receive periodic medical examinations. Payment for these
examinations is the responsibility of the parent/guardian. THESE IMMUNIZATIONS ARE REQUIRED FOR SCHOOL ATTENDANCE. Attach a copy of
the student’s immunization record, or record the dates below.
ENTER MONTH, DAY, AND YEAR EACH IMMUNIZATION WAS GIVEN
VACCINE
DOSES
Diptheria and Tetanus* (DTap, DTP, Td or DT)
/
/
/
/
/
/
/
/
1.
2.
3.
4.
/
/
5.
Polio, (OPV or IPV)
/
/
/
/
1.
2.
/
/
3.
4.
/
/
Hepatitis B
/
/
/
/
/
/
1.
2.
3.
Measles** - Mumps - Rubella (MMR)
/
/
/
/
1.
2.
or Measles Serology:
Date
Titer
Varicella
/
/
/
/
Rubella Serology:
Date
Titer
1.
2.
Other
/
/
Mumps disease diagnosed by a physician:
Date
/
/
1.
2.
Date of last Tetanus Booster______________
Date of last PPD_________________ Result______________mm
*
One dose must be on or after the fourth (4th) birthday.
Does this student have health insurance?
___ Yes
___ No
**
First dose must be on or after the first (1st) birthday and the second dose
should be at least one month after the first dose
Name of Insurance Provider:_______________________________
RECORD THE FOLLOWING
1.
Visual Acuity:
Without Glasses:
R______
L______
With Glasses:
R______
L______
2.
Audiometric Screening:
R______
L______
3.
BP_____________
4.
Height ___________inches / cm
Weight ___________lb. / kg
BMI percentile ___________
5.
Scoliois Screening:
____ Normal
____ Abnormal
____ Referred
____ No Referral
6.
Activity Recommendation:
____ Full Physical Activity
____ Restricted Physical Activity
(Must Complete Phys. Ed. Medical Exemption/Program Modification Form MEH-23)
Specify Restrictions: ________________________________________________________________________________________________
7.
List all medications currently being taken:
Medication:______________________________________________________________
Reason:________________________________
8.
List ALL problems by history or examination:
Circle status of problem
1. ________________________________________________________________
Under Care
Care Complete
Referred
2. ________________________________________________________________
Under Care
Care Complete
Referred
3. ________________________________________________________________
Under Care
Care Complete
Referred
____ No Problems Identified
Comments / follow-up treatment plan / Special instructions to school:
Signature of Care Provider (REQUIRED)
Telephone
Care Provider office stamp (REQUIRED)
Address
Date of Exam
MEH-1 (Rev. 9/05) Comm. Code 61602445214
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Parent category: Medical