School Entrance Health Form - Virginia

MCH 213G reviewed 03/2014
1
COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM
Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part I HEALTH INFORMATION FORM
State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public
kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the
form. This form must be completed no longer than one year before your child’s entry into school.
Name of School: ____________________________________________________________________________________ Current Grade: _______________________
Student’s Name: _________________________________________________________________________________________________________________________
Last First Middle
Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________
Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________
Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Condition
Yes
Comments
Condition
Yes
Comments
Allergies (food, insects, drugs, latex)
Diabetes
Allergies (seasonal)
Head injury, concussions
Asthma or breathing problems
Hearing problems or deafness
Attention-Deficit/Hyperactivity Disorder
Heart problems
Behavioral problems
Lead poisoning
Developmental problems
Muscle problems
Bladder problem
Seizures
Bleeding problem
Sickle Cell Disease (not trait)
Bowel problem
Speech problems
Cerebral Palsy
Spinal injury
Cystic fibrosis
Surgery
Dental problems
Vision problems
Describe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,
etc.):__________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly:
_______________________________________________________________________________________________________________________________________
Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No
Please provide the following information:
Name
Phone
Date of Last Appointment
Pediatrician/primary care provider
Specialist
Dentist
Case Worker (if applicable)
Child’s Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored
I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the
school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you
withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record,
documentation of the disclosure is maintained in your child’s health or scholastic record.
Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________
Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________
Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______
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