School Entrance Health Form - Commonwealth Of Virginia printable pdf download

COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Health Information Form / Comprehensive Physical Examination Report / Certification of Immunization

HEALTH INFORMATION FORM

Part I -

Part I to be completed by parents or guardians of entering students. Ref. Code of Virginia § 22.1-270, I.

Student’s Name: ______________________________________________________________________________________________________________

Last

First

Middle

Student’s Date of Birth: |___|___|___| Sex: |___| Number of Children in Family: |___| State or Country of Birth: ____________________________________

Mo. Day

Yr.

Student’s Social Security #: |___|___|___| - |___|___| - |___|___|___|___| or I.D. #: _________________________________________________________

Student’s Address: ________________________________________

City: _________________________ State: ______ Zip: |___|___|___|___|___|

Name of School: ____________________________________________________________________________________ Grade: __________________

Name of Mother or Legal Guardian: _______________________________________________________________________________________________

Home Phone: |___|___|___| - |___|___|___| - |___|___|___|___|

Work Phone: |___|___|___| - |___|___|___| - |___|___|___|___|

Area Code

Name of Father or Legal Guardian: ________________________________________________________________________________________________

Home Phone: |___|___|___| - |___|___|___| - |___|___|___|___|

Work Phone: |___|___|___| - |___|___|___| - |___|___|___|___|

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: |___|___|___| - |___|___|___| - |___|___|___|___|

Birth History (weight, premature, and any other problems at birth): _______________________________________________________________________

____________________________________________________________________________________________________________________________

ALLERGIES (food, medicine, insect bites, and any other allergies): ___________________________________________________________________

____________________________________________________________________________________________________________________________

Equipment Used and Specialized Health Care Needed

Chronic, Recurring, and Special Health Conditions

(Check all that apply and explain below. *)

Equipment Used by Child:

Catheterization

Arthritis (rheumatoid)

Glasses / Contact Lens

Clean Intermittent Catheterization

Asthma

Hearing Aid

External Catheter

Attention-Deficit/Hyperactivity Disorder

Helmet

Other:

Behavioral or Developmental Problems

Wheelchair / Walker

Medical Support Systems

Cerebral Palsy

Other:

Hickman / Broviac / IVAC/ IMED

Cystic Fibrosis

Mechanical Ventilator

Dental Problems

Oxygen

Diabetes

Specialized Health Care Needed:

Ventricular Peritoneal Shunt

Encopresis (involuntary discharge of stool)

Activities of Daily Living

Other:

Enuresis (involuntary discharge of urine)

Bowel / Bladder Training

Ostomies

Head or Spinal Injury

Diapering / Toileting

Ostomy Care

Hearing Impairment

Lifting / Positioning

Other:

Heart Disease

Other:

Respiratory Assistance

Kidney Disease

Feeding

Percussion

Muscular Dystrophy

Gastrostomy Feeding

Postural Drainage

Seizures

Jejunostomy Tube Feeding

Suctioning

Sickle Cell Disease (not trait)

Naso-Gastric Feeding

Other:

Spina Bifida

Oral Feeding

Specimen Collecting / Testing

Visual Impairment

Total Parenteral Feeding

Blood Glucose

Other:

*Explanation:

Describe any family history of chronic illnesses or genetic concerns (please list family member in relation to child [e.g., mother] and name of condition

[e.g., anemia, arthritis, cancer, diabetes, heart disease, high blood pressure, kidney disease, mental illness, stroke, tuberculosis]): ___________________

___________________________________________________________________________________________________________________________

List names of medical specialists or special clinics caring for your child: __________________________________________________________________

___________________________________________________________________________________________________________________________

Has your child ever been seen by a dentist? Yes: |___|, No: |___|. If yes, date of last appointment: ________ Name of dentist: ______________________

List all prescription and over-the-counter medications taken regularly by your child: _________________________________________________________

___________________________________________________________________________________________________________________________

Describe your child’s operations and hospitalizations, if any (reason and date): ____________________________________________________________

Describe any other important health-related information about your child: _________________________________________________________________

___________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with 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.): |___|___|___|

MCH-213 D, PART I, REV. 1/99