School Physical Form - State Of Rhode Island printable pdf download

School Name & Address:

Health Care Provider Name and Address:

STATE OF RHODE ISLAND

Phone:

SCHOOL PHYSICAL FORM

This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format

with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)

Student Name: Last

First

Middle

Date of Birth

Sex

Address: Street

Apt #

City

State

Zip Code

Home Phone

PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript). The requested information is in accordance with the State of Rhode Island Rules and

Regulations for: Immunization and Testing for Communicable Disease, School Health Programs, and Lead Poisoning Prevention. Website:

IMMUNIZATIONS

Hepatitis B

_____/_____/_____

Diphtheria-Tetanus- Pertussis

_____/_____/_____

Check

if DT

Check

if DT

Check

if DT

Check

if DT

Check

if DT

DTP/DTaP

_____/_____/_____

Pneumococcal Conjugate

PCV

Polio

_____/_____/_____

IPV or

OPV

IPV or

OPV

IPV or

OPV

IPV or

OPV

Haemophilus Influenzae Type B

_____/_____/_____

Hib

Measles-Mumps-Rubella

____/_____/_____

_____/_____/_____

MMR

Varicella

_____/_____/_____

Student has history of varicella disease

Tetanus-Diphtheria-Pertussis

_____/_____/_____

Tdap

Tetanus-Diphtheria

_____/_____/_____

_____/____/_____

Meningococcal

_____/_____/_____

Immunization Exemption: Medical

Religious

Hepatitis B

DTaP

IPV

Hib

PCV

MMR

Varicella

Td/Tdap

PHYSICAL EXAMINATION

Date of PE _____/_____/_____

Height ___________

Weight___________

BP____________

Please note any health problem, chronic health condition or disability that may affect behavior or health at school:

ASTHMA: No

Yes

DIABETES: No

Yes

OTHER: ___________________________________________________________________

Significant Systems Findings: __________________________________________________________________________________________________________________

ALLERGIES: No

Yes

(Please explain) ___________________________________________EPINEPHRINE AUTO-INJECTOR REQUIRED: No

Yes

Treatment Plan: ____________________________________________________________________________________________________________________________

MEDICATION (REQUIRED AT SCHOOL): No

Yes

(Please list) _______________________________________________________________________

Other medication(s) that may affect behavior or health at school: _____________________________________________________________________________________

RESTRICTIONS: Can participate in physical education:

Fully

With limitation

_____________________________________________________

Can participate in sports:

Fully

With limitation

_____________________________________________________

LEAD SCREENING (Required for children < 6 years of age only)

VISION SCREENING (Required for children entering kindergarten)

SCOLIOSIS SCREENING

Student is in compliance with lead screening requirements: