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Get Ca Pm 171 A 2001

State of California Health and Human Services Agency Primary Care and Family Health Division Department of Health Services Children s Medical Services Branch Child Health and Disability Prevention CHDP Program REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY To protect the health of children California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school* The school will keep and maintain it as confidential information* PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD S NAME Last First ADDRESS Number/Street City Middle BIRTHDATE Month/Day/Year ZIP Code SCHOOL HEALTH EXAMINATION IMMUNIZATION RECORD NOTE All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age. Note to Examiner Please give the family a completed or updated yellow California Immunization Record. Note to School Please record immunization dates on the blue California School Immunization Record PM 286. REQUIRED TESTS/EVALUATIONS Health History Physical Examination Dental Assessment Nutritional Assessment Developmental Assessment Vision Screening Audiometric hearing Screening Tuberculin Test Mantoux/PPD Blood Test for anemia Urine Test Blood Lead Test Other DATE EACH DOSE WAS GIVEN DATE VACCINE Second Third Fourth Fifth POLIO OPV or IPV DTaP/DTP/DT/Td diphtheria tetanus and acellular pertussis OR tetanus and diphtheria only MMR measles mumps and rubella HIB MENINGITIS Haemophilus Influenzae B Required for child care/preschool only HEPATITIS B VARICELLA Chickenpox OTHER ADDITIONAL INFORMATION FROM HEALTH EXAMINER optional and RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN RESULTS AND RECOMMENDATIONS Fill out if patient or guardian has signed the release of health information* I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III. Examination shows no condition of concern to school program activities. Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are please explain Please check this box if you do not want the health examiner to fill out Part III. Signature of parent or guardian Date Name address and telephone number of health examiner Signature of health examiner PM 171 A 1/01 Bilingual If your child is unable to get the school health check-up call the Child Health and Disability Prevention CHDP Program in your local health department. If you do not want your child to have a health check-up you may sign the waiver form PM 171 B found at your child s school*. Please have this report filled out by a health examiner and return it to the school* The school will keep and maintain it as confidential information* PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD S NAME Last First ADDRESS Number/Street City Middle BIRTHDATE Month/Day/Year ZIP Code SCHOOL HEALTH EXAMINATION IMMUNIZATION RECORD NOTE All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age. Note to Examiner Please give the family a completed or updated yellow California Immunization Record. .

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