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Student Address Label
Medical StatuS
Department of Education
StudentS HealtH RecoRd
Name
Birthdate
Parent’s Name
(Last) (First) (Middle Initial)
Month Day Year
Please complete the following sections (CHECK IF YES)
Date
Read
Results
(mm)
Physician, APRN, PA, or Clinic
Date
Given
Location
Date
Results
tubeRculoSiS exaMination
Mantoux teSt (intRadeRMal)
cHeSt x-Ray
/ /
/ /
/ /
/ /
dental exaMination
/ /
Dental Check-Up
*OFFICE USE ONLY (Rev. 2010)
Preschool: Entry Date
Elementary: Entry Date
Intermediate/Middle: Entry Date
High: Entry Date
Female
Male
/ /
/ /
/ /
/ /
PHySicianS exaMination code: n-noRMal; a-abnoRMal; c-coRRected; R-Receiving caRe
Date
/ /
/ /
Weight
Grade
Height
Extremities
Scoliosis
Blood
Pressure
Skin
Abdomen
Lungs
Heart
Teeth
Throat
Nose
Eyes
HearingVision
Nervous
System
R. L. R. L.
Ears
Nutrition
Provider’s Stamp
or Printed Name
Provider’s Signature
Reviewed
Immunization
Record
(Check if Yes)
Varicella
Immunity
Secondary to
Disease (DATE)
Completed
PPD Screening
(Check if Yes)
See Results Below
/ /
/ /
BMI
Allergy (type) Cancer/Leukemia Hearing Problems Hypertension Seizures ❑ Vision Problem
Asthma Chronic Cough/Wheezing Heart Disease JRA Arthritis Sickle Cell Anemia
Behavioral Problems Diabetes Hemophilia Rheumatic Heart Skin Problems
Physician, APRN, PA or Clinic
iMMunizationS (vaccineS, dateS given: MontH/day/yeaR)
Type
Date
/ / / / / / / / / / / /
Type
Date
/ / / / / / / / / / / /
Type
Date
/ / / / / / / / / / / /
Type
Date
/ / / / / / / / / / / /
Type
Date
/ / / / / / / / / / / /
Date
/ / / / / /
Varicella
/ / / /
Date
/ / / /
Type
Date
/ / / / / / / / / / / /
Type
Date
/ / / / / / / / / / / /
DTaP, DTP, DT,
Tdap or Td
Polio
(IPV or OPV)
Hib (Haemophilus
inuenzae type b )
Pneumococcal
Conjugate
Hepatitis B
MMR
Hepatitis A
Other
Other
Allergies:
(Mother/Legal Guardian)
(Father/Legal Guardian)
Student's Health Record
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