Health Care Provider'S Examination Form - Massachusetts School Health Record

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MASSACHUSETTS SCHOOL HEALTH RECORD
Health Care Provider’s Examination
Name ________________________________________
Male
Female Date of Birth:___________________
Medical History _________________________________________________________________________________________
_______________________________________________________________________________________________________
Pertinent Family History
Current Health Issues
Y
N
Allergies: Please list: Medications ______________________ Food _________________ Other ______________
History of Anaphylaxis to ___________________ Epi-Pen:
Yes
No
Asthma: Asthma Action Plan
Yes
No (Please attach)
Diabetes:
Type I
Type II
Seizure disorder: ____________________________________________________________________________
Other (Please specify) _________________________________________________________________________
Current Medications (if relevant to the student's health and safety) Please circle those administered in school; a separate
medication order form is needed for each medication administered in school.
Physical Examination
Date of Examination:___________________________
Hgt: ________(_____%) Wgt:_________(_____%) BMI: _________(_____%) BP: ________
(Check = Normal / If abnormal, please describe.)
General ________________
Lungs __________________
Extremities _____________
Skin __________________
Heart ___________________
Neurologic _____________
HEENT _______________
Abdomen _______________
Other __________________
Dental/Oral ____________
Genitalia ________________
Screening:
(
Pass) (Fail)
(Pass) (Fail)
(Pass) (Fail)
Vision: Right Eye
Hearing: Right Ear
Postural Screening:
Left Eye
Left Ear
(Scoliosis/Kyphosis/Lordosis)
Stereopsis
Laboratory Results:
Lead _______ Date _______________
Other____________________________________
The entire examination was normal:
Targeted TB Skin Testing:
Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors):
TB Test Type:
TST
IGRA Date: ____________ Result:
Positive
Negative
Indeterminate/Borderline
Referred for evaluation to: _______________________________________
Low risk (no TST done)
This student has the following problems that may impact his/her educational experience:
Vision
Hearing
Speech/Language
Fine/Gross Motor Deficit
Emotional/Social
Behavior
Other
_____________________________________________________________________
:
Comments/Recommendations
Y
N This student may participate fully in the school program, including physical education and competitive sports. If
no, please list restrictions:_____________________________________________________________________________________
Y
N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System
Certificate or other complete immunization record.
______________________________________________
___________________________________________
Signature of Examiner Circle: MD, DO, NP, PA
Date
Please print name of Examiner.
______________________________________________
Group Practice
Telephone
___________________________________________________________________________________________________________
Address
City
State
Zip Code
Please attach additional information as needed for the health and safety of the student.
MDPH 10/18/13

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