School Physical Form
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1School Name & Address:
Health Care Provider Name and Address:
STATE OF RHODE ISLAND
Grade: ________________
Phone:
SCHOOL PHYSICAL FORM
This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format
with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)
Student Name: Last
First
Middle
Date of Birth
Sex
Address: Street
Apt #
City
State
Zip Code
Home Phone
PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript).
IMMUNIZATIONS
Please enter dates in MM/DD/YYYY format
Hepatitis B
Diphtheria-Tetanus-Pertussis
DTaP < 7 years
Pneumococcal Conjugate
PCV
Polio
Haemophilus Influenzae Type B
Hib
Measles-Mumps-Rubella
MMR
Varicella
Student has history of varicella disease
Tetanus-Diphtheria-Pertussis
Tdap/Td > 7 years
Rotavirus
Hepatitis A
Meningococcal
HPV
Influenza
Medical Exemption:
Hep B
DTaP
PCV
Polio
Hib
MMR
Varicella
Td/Tdap
Rotavirus
Hep A
Mening
HPV
Influenza
PHYSICAL EXAMINATION
Date of PE _____/_____/_____
Height ___________
Weight___________
BP____________
P
,
:
LEASE NOTE ANY HEALTH PROBLEM
CHRONIC HEALTH CONDITION OR DISABILITY THAT MAY AFFECT BEHAVIOR OR HEALTH AT SCHOOL
1. ASTHMA:
No
Yes If yes, complete an
Asthma Action Plan
(
)
2. ALLERGIES: No
Yes (Please explain) __________________________________EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes
If student has a severe allergy (food, insect, other) complete a
Food Allergy& Anaphylaxis Emergency Care Plan (
)
3. DIABETES: No
Yes If yes, complete a
Physicians Order Form For Students With Diabetes
( )
4. OTHER: ________________________________________________________________________________________________________________________________
Treatment Plan: ____________________________________________________________________________________________________________________________
RESTRICTIONS: Can participate in physical education/sports:
Fully
With limitation _______________________________________________________
MEDICATION (REQUIRED AT SCHOOL): No
Yes (Please list) _______________________________________________________________________
Other medication(s) that may affect behavior or health at school: _____________________________________________________________________________________
LEAD SCREENING (Required for children < 6 years old)
SCOLIOSIS SCREENING
VISION SCREENING (Children entering Kindergarten)
Student is in compliance with lead screening requirements:
Yes No
Passed Screening
Screened & referred for comprehensive exam
Yes No
Referred for comprehensive exam, but not screened
TUBERCULOSIS (If required by school district)
Screening / Referral
Comprehensive
Date of TB test:
Date:
Exam Date:
HEALTH CARE PROVIDER SIGNATURE:
________________________________________________________________
DATE: _________________________________
PRINT NAME:
________________________________________________________________
6-2016
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Parent category: Medical