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H511.336 (Rev. 6/97)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
PRIVATE PHYSICIAN'S REPORT OF PHYSICAL EXAMINIATION OF A PUPIL OF SCHOOL
AGE
DATE______________________
NAME OF SCHOOL_____________________________GRADE_____ HOMEROOM_________
___________________________________________________ ______ M_____ F_____
Last Name of Child
First
Middle
Age
Sex
ADDRESS
________________________________________________________________________________________________
No and Street City or Post Office Borough or Township
________________________________________________________________________________________________
County State Zip Code
PENNSYLVANIA DEPARTMENT OF HEALTH - CERTIFICATE OF IMMUNIZATION
VACCINE
Circle appropriate item |
Enter, Month, Day, and Year Each
Immunization
Was Given DOSES BOOSTERS & DATES |
| Diphtheria and Tetanus* |
1 / / |
2 / / |
3 / / |
4 / / |
5 / / |
| Polio |
1 / / |
2 / / |
3 / / |
4 / / |
5 / / |
| Measles, Mumps, Rubella |
1 / / |
2 / / |
|
|
| Hepatitis B |
1 / / |
2 / / |
3 / / |
| HIB |
1 / / |
2 / / |
3 / / |
| Other (Varicella) |
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| *Tetanus and Diphtheria are usually received
in combined vaccines such as DTP, DT, or Td |
|
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Medical Exemption the physical condition of the
above named is such that immunizations would endanger life or health
Religious Exemption (Include a strong moral or ethical conviction similar
to a religious belief and requires a written statement from the parent/guardian)
Tuberculin Tests
Date Applied |
Arm |
Device |
Antigen |
Manufacturer |
Signature |
| |
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Date Read |
Results (mm) |
Signature |
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Follow-Up of significant tuberculin tests:
Parent/Guardian notified of significant findings on _________________________.
Date
Results of Diagnostic Studies: ___________________________.
Date
Preventive Anti-Tuberculosis - Chemotherapy ordered. No _____ Yes _____ Date:
_________________
Significant Medical Conditions (3 )
| |
Yes |
No |
If Yes, Explain |
| Allergies |
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| Asthma |
|
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| Cardiac |
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| Chemical Dependency |
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| Drugs |
|
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| Alcohol |
|
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| Diabetes Mellitus |
|
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| Gastrointestinal Disorder |
|
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| Hearing Disorder |
|
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| Hypertension |
|
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| Neuromuscular Disorder |
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| Orthopedic Condition |
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| Respiratory Illness |
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| Seizure Disorder |
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| Skin Disorder |
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| Vision Disorder |
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| Other (Specify) |
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Report of Physical Examination (ü
)
| |
Normal |
Abnormal |
If Abnormal, Explain |
| Height (inches) |
|
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| Weight (pounds) |
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| Pulse ( ) |
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| Blood Pressure / |
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| Hair/Scalp |
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| Skin |
|
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| Eyes – Visual Acuity R___/___ L___/___ |
|
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| Eyes – Color Vision |
|
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| Ears – Hearing dB R L |
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| Nose and Throat |
|
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| Teeth and Gingiva |
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| Lymph Glands |
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| Heart – Murmur, etc. |
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| Lung – Adventious Findings |
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| Abdomen |
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| Genitalia |
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| Neuromuscular System |
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| Extremities |
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| Spine (Presence of Scoliosis) |
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_________________________________________________
Date of Examination
_________________________________________________
________________________________________
Signature of Examiner
Print
Name of Examiner
_________________________________________________
Address
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