San Francisco School Health Form printable pdf download

San Francisco Unified School District - School Health Form

Completed by Parent or Caregiver:

Child’s Name:

Birthdate:

Male

Female

School:

Last,

First

month/day/year

Address:

Phone:

Grade:

Street

Zip

Home

Cell

Work

Release of Health Information: I give permission to share the results of this examination with the School ____________________________

______________________

Signature of Parent/Caregiver

Date

NOTE: Kindergarten entrance physical examination to be done no earlier than March of the year the child enters Kindergarten

Completed by health provider:

IMMUNIZATION RECORD (EACH child should have a completed or updated official/ yellow Immunization Record)

Dose Given: Month / Day / Year

Tuberculin Skin Test (Mantoux/PPD)

Date: ___________________

Vaccine

□

□ Po

Polio (IPV)

Induration: _____mm

Impression:

Negative

sitive

DTaP (Diphtheria, Tetanus, Pertussis)

Chest X-Ray/RX: Required with Positive TB Skin Test

□

Td/ Tdap (Tetanus, Diphtheria, Pertussis)

CXR Date:________

Impression:

Negative

Positive

Hib (Haemophilus influenza type B)

RX treatment & duration: _____

_________

 Child has no risk factors for TB and does not require TB test

MMR (Measles, Mumps, Rubella)

Not to be given before the 1

birthday

*See back for risk factors

Hepatitis B

Health Provider Signature

Varicella (Chickenpox)

Had Varicella disease - Approximate date ________

HEALTH EXAMINATION – Date of Exam___________________

Results:

Summary of Findings/Conditions:

Follow-up/Referral Needed :

Health/Developmental History

Physical Examination

Ht: _______ BP: _______

Wt: _______ BMI: ______%

Dental Assessment

Developmental Evaluation

Vision Screening

R: 20/__

L: 20/__ Both:20/__

Audiometric (hearing)

500

1000

2000

4000

Screening

Right:

Left:

Nutritional Assessment

Lab Tests

Urine______________ Lead _______

Blood test for anemia________

Other

(If you do not want your child to have an exam, you may sign the waiver form, PM 171B, obtained from your child’s school) See other side for more details

 Examination revealed no condition relevant to the school program, e.g. allergies, asthma, cardiac condition, diabetes, epilepsy, etc.

 Medical condition identified – Emergency care plan completed – available on the Student Support Services Department (SSSD) website

 Medication taken at school – Name of medication: ______________________

Medication taken at home – Name of medication: ______________________

(If medication is taken at school, complete a medication form for each medication – available on the SSSD website

)

 Restriction from physical activity – please specify

Name of Health Provider:

Child under my care since _________________________.

Address:

Phone:

Signature of Health Provider:_____________________________________ Date: ___________________

SFUSD School Health Form – page 1 2011/2012

San Francisco School Health Form

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