Health Appraisal Form (Page 2 of 2) in pdf

Health Appraisal Form Page 2

Health Appraisal Form

Student Name: _______________________________________________

DATE OF MOST RECENT MANTOUX TUBERCULIN:

TEST: __________ RESULT: __________ FOLLOW-UP: _____________________

COMPLETE IMMUNIZATION HISTORY (OR ATTACH COPY)

DPT/DTaP

Tdap (Grade 6)

Polio

MMR

Measles

(on or after 1

birthday)

Mumps

(on or after 1

birthday)

Rubella

(on or after 1

birthday)

Hib (after 1st birthday)

Hepatitis B

Varicella

(on or after 1

birthday)

Meningococcal

(Grade 6)

Pneumococcal (Pre-School)

(after 1

birthday)

Influenza

(Pre-School)

PLEASE LIST ANY HEALTH PROBLEMS WHICH MIGHT INTERFERE WITH THE

STUDENT’S EDUCATIONAL PROGRAM OR LIMIT HIS/HER PARTICIPATION IN

THE REGULAR PHYSICAL EDUCATION PROGRAM:

INDICATE ANY RESTRICTIONS:

COMMENTS:

DATE OF EXAMINATION: _______________________

SIGNATURE OF PHYSICIAN: ___________________________________

PRINTED NAME, ADDRESS AND TELEPHONE: ____________________________

____________________________

HS2ee Revised 08/2014

Health Appraisal Form Page 2