Physical Health Examination Form Page 2
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4WINGS -JAYC II, LLC
Office - 320-593-0440; Fax 320-593-0442
Physical Health Examination
Mantoux:
Date of last Mantoux Test: ______________ We prefer Mantoux test or check X-ray be done
Results:
Negative
Positive
(Circle one)
Or date of last chest X-ray: ________________________________
Result of last Chest X-ray: ____________________________
Is this resident free from communicable disease: Yes
No
(Circle One)
Does this resident have a form of herpes:
Yes
No
(circle one)
Immunizations: Have you been immunized against:
Small Pox
(
) No (
) Yes
Last shot___________________
Tetanus
(
) No (
) Yes
Last shot___________________
Polio (shots/oral Vaccine)
(
) No (
) Yes
Last shot____________________
Measles
(
) No (
) Yes
Last shot____________________
German Measles
(
) No (
) Yes
Last shot____________________
Other
(
) No (
) Yes
Last shot____________________
_______________________
Prescribed Medication/Treatment Orders: Current medication and treatments are listed. Unless
otherwise specified, all medications/treatments are good for one year.
1.
2.
3.
4.
5.
6.
No Medications _________________________ (please check if this applies)
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Parent category: Education