Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization Page 2
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COMPREHENSIVE PHYSICAL EXAMINATION REPORT
Part II -
Part II must be completed by a qualified licensed physician. nurse practitioner, or physician assistant. The exam must be done within one year before
enrollment in kindergarten or elementary school (Ref. Code of Virginia § 22.1-270).
Student’s Name: _____________________________________________________________________________________________________________
Last
First
Middle
Date of Birth: |_____|_____|_____|
Sex: _____ (M/F)
Height: _______
Weight: _______
BMI Percentile _______
Blood Pressure: ___________
Mo.
Day
Yr.
Required Screening Tests (see Part IV)
Explanation
Result
Anemia Screen (questions on back of form)
If positive, do hemoglobin or hematocrit
Neg:
Hgb or Hct:
Urine Screen
Dipstick urine for glucose, protein, & other
Glucose:
Protein:
Other:
Vision Screen
Distance visual acuity without correction
Right: 20/
Left: 20/
Both: 20/
Distance visual acuity with correction
Right: 20/
Left: 20/
Both: 20/
Stereopsis (Ocular Alignment)
Description on back of form
Pass:
Fail:
Hearing Screen
Must be done with pure tone audiometry at 20 dbl
Right:
Left:
Lead level (criteria on back of form)
Blood lead level
Date:
Result:
Optional Screening Tests (see Part IV)
Tuberculin skin test (criteria on back of form)
May be required in high-risk groups
Pos:
Neg:
Date:
Vision Screening:
Please print all pages
Child to be rescreened? Yes |___|, No |___|
Child to be referrred? Yes |___|, No |___|
Hearing:
Child to be rescreened? Yes |___|, No |___|
Child to be referred? Yes |___|, No |___|
Not
Normal
Abnormal
Examined
Comments About Findings
Systems Examination
General Appearance
Skin
Head
External
Eyes:
Fundi
External and Canal
Ears:
Tympanic Membrane
Nose
Throat
Mouth / Teeth
Neck
Chest
Heart
Lungs
Abdomen
Genitalia (Tanner Stage)
Bones, Joints, Muscles
Neurological
Posture / Range of Motion
Other:
Comments
Cognitive Development
Estimated
Speech / Language Development
Developmental
Social / Emotional Development
Level:
Health Behaviors / Health Habits
Assessment including medical diagnoses and potentially disabling conditions that might require (1) educational evaluation, (2) environmental adjustment,
or (3) activity limitation: ______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Recommendations: _________________________________________________________________________________________________________
MCH-213 E, PART I (Rev. 10/03)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Referrals made, if any: _______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Medical Provider’s Name (print):_______________________________________________ Phone No. |___|___|___| - |___|___|___| - |___|___|___|___|
Medical Provider’s Address: ___________________________________ City: _________________________ State: _____ Zip: |___|___|___|___|___|
Signature of Medical Provider: __________________________________________________________________ Date (Mo., Day, Yr.):|___|___|___|
MCH-213 E, PART II (Rev. 10/03)
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