Health Services/health Appraisal Form Page 2
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2STUDENT’S NAME: __________________________________________________________________________
DATE OF MOST RECENT TUBERCULIN TEST (MANTOUX): ______________________________________
RESULT: _______________________________________
FOLLOW-UP: ______________________________
DATES OF MOST RECENT IMMUNIZATION GIVEN, OR DATES OF ALL IMMUNIZATIONS
FOR NEWLY REGISTERED STUDENTS ENROLLING IN PRE-K OR KINDERGARTEN:
POLIO: ___________________
DTP: ______________________
DT: ______________________
MEASLES: ________________
RUBELLA: ________________
MUMPS: _________________
OTHER: _____________________________________________________________________________
===========================================================================
PLEASE LIST ANY HEALTH PROBLEMS WHICH MAY INTERFERE WITH THE STAFF MEMBER’S
EDUCATIONAL PROGRAM OR LIMIT HIS/HER PARTICIPATION IN THE REGULAR SCHOOL
PROGRAM AND INDICATE ANY RESTRICTIONS:
________________________________________
___________________________________________
DATE OF EXAMINATION
PHYSICIAN SIGNATURE
PRINTED NAME AND ADDRESS OF PHYSICIAN:
_________________________________________________
_________________________________________________
_________________________________________________
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Parent category: Medical