Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization

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COMMONWEALTH OF VIRGINIA
Please print all pages
SCHOOL ENTRANCE HEALTH FORM
Health Information Form / Comprehensive Physical Examination Report / Certification of Immunization
HEALTH INFORMATION FORM
Part I -
State law (Ref. Code of Virginia § 22.1-270) requires that your child is completely immunized and receives a comprehensive physical examination before
entering public kindergarten. The parent or guardian completes this page of the form. The Medical Provider completes the second and third pages of the
form. This form must be completed within one year before your child’s first day in kindergarten or elementary school.
Name of School: _____________________________________________________________________________________ Grade: _________________
Student’s Name: ______________________________________________________________________________________________________________
Last
First
Middle
Student’s Date of Birth: |______|______|______|
Sex: |____|
State or Country of Birth: ________________________________________
Mo.
Day
Yr.
Student’s Social Security #: |___|___|___| - |___|___| - |___|___|___|___| or I.D. #: ________________________________________________________
Student’s Address: _______________________________________City: _________________________ State: ___________
Zip: ________________
Name of Mother or Legal Guardian: ______________________________________________________________________________________________
Home Phone: |___|___|___| - |___|___|___| - |___|___|___|___|
Work Phone: |___|___|___| - |___|___|___| - |___|___|___|___|
Area Code
Area Code
Name of Father or Legal Guardian: _______________________________________________________________________________________________
Home Phone: |___|___|___| - |___|___|___| - |___|___|___|___|
Work Phone: |___|___|___| - |___|___|___| - |___|___|___|___|
Area Code
Area Code
In case of emergency—if parent or guardian cannot be contacted—contact the following:
1.
Name: _______________________________________________ Complete Phone Number: |___|___|___| - |___|___|___| - |___|___|___|___|
2.
Name: _______________________________________________ Complete Phone Number: |___|___|___| - |___|___|___| - |___|___|___|___|
___________________________________________________________________________________________________________________________
Assessment of Student’s Health
To the best of your knowledge, has your child had any problem with the following? Please check yes or no.
Condition
Yes
No
Comments if “Yes”
Allergies (food, insects, drugs, latex)
Allergies (seasonal)
Asthma or breathing problems
Attention-Deficit/Hyperactivity Disorder
Behavioral problems
Developmental problems
Bladder problem
Bleeding problems
Bowel problem
Cerebral Palsy
Cystic Fibrosis
Dental problems
Diabetes
Head or spinal Injury
Hearing problems or deafness
Heart problems
Hospitalizations (when, why)
Lead poisoning
Muscular problems
Seizures
Sickle Cell Disease (not trait)
Speech problems
Surgery
Vision problems
Other:
List all prescription and over-the-counter medications your child takes regularly: ___________________________________________________________
__________________________________________________________________________________________________________________________
Describe any other important health-related information about your child (i.e., feeding tube, oxygen support, hearing aid, etc.): ______________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Name of your child’s pediatrician or primary care provider: ____________________________________________________________________________
Names of medical specialists or special clinics caring for your child: ____________________________________________________________________
__________________________________________________________________________________________________________________________
Has your child ever seen a dentist? Yes: |___|, No: |___|.
If yes, date of last appointment: ___________________
Check here if you want to discuss confidential information with the school nurse or other school authority: Yes |___|, No |___|.
Check here if you give permission for the school nurse or other school authority to contact the examining physician to discuss any information contained on
this form: Yes |___|, No |___|.
Signature of Parent or Legal Guardian: ____________________________________________________________ Date (Mo., Day, Yr.): |___|___|___|
Signature of Interpreter: __________________________________________________________________________ Date (Mo., Day, Yr.): |___|___|___|
MCH-213 E, PART I (Rev. 10/03)

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