DH 3040, 6/02 (Obsolet es previous editi ons which m ay not be us ed) St oc k Number: 5744-000-3040-2
School Entry Health Exam
Page 2 of 2
Name of C hild (Las t, First, M iddle ) Birth Date
PART II — MEDICAL EVALUATION
To be completed and signed by the Health Care Provider ONLY:
The c hild named above has had a complete history and physical e xam on the followi ng date:
(Exam must be within one year of enrollment)
Month Day Year
Height: Weight: BMI%: B/P: Hct/Hgb: Lead: Urinalysis:
Vision - Without Glasses
Right 20/_____ Left 20/_____
Hearing – Ri ght Passed Failed Referred
Vi sion - With Glasses
Right 20/_____ Left 20/_____
Hearing – Left Passed Failed Referred
Gross dental (teeth and gums) Normal Abnormal Refer/Tx:
Normal Abnormal Refer/Tx:
Eyes/Ears/Nose/Throat Normal Abnormal Refer/Tx:
Chest/Lungs/Heart Normal Abnormal Refer/Tx:
Abdomen Normal Abnormal Refer/Tx:
Postural assessment Normal Abnormal Refer/Tx:
TB risk assessment done
(Please review Targeted Testing Guidelines listed below.)
This child has the following problems that may impact the educational experience:
Vision Hearin g Speech/Language Physical Social/Behavioral Cognitive
This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below.
(This form will be stored in the child ’s Cumulative Health Folder an d m ay be accessed by both scho ol and health perso nnel.)
Recommendations (Attach additional sheet if necessary):
(Please Check One)
This child may participate fully in school activities including physical education.
This child may participate in school activities including physical education with the following restriction/adaptation.
(Specify reason and restriction)
Signature/Title of Health Care Provider Date Address (Please print or stamp)
Name (Please print or stamp)
Tuberculosis Targeted Testing Guidelines for Health Care Providers
Tubercul osis Infection Risk:
Review the following risks and administer a Mantoux TB skin test if child is in one or more categories. The TB test is administered confidentially
as part of the health examination. Do not record administration of any TB test or related information on this form.
· Recent immigrant (< 5 years), frequent visitor to TB endemic areas
· Close contact to active TB case
· Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user
· HIV+ or have other medic al conditions that i ncrease the ris k to progress from infecti on to dis ease, e.g., chronic renal failure,
diabetes, hematologic or any ot her malignancy, wei ght los s > 10% of ideal body weight, on immunosuppr essi ve medicati ons
Active TB Disease Risk:
· Does the chi ld exhib it s igns/ symptoms of tuberculosi s (e. g. cough f or thr ee weeks or longer, weight loss , los s of app etite)?
· If symptoms are present, work-up or refer for TB disease evaluation.