Massachusetts School Health Record Health Care Providers Examination

In order to evaluate the health of students in the State of Massachusetts, the following form has to be completed and submitted.

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MASSACHUSETTS SCHOOL HEALTH RECORD	
Health  Care Provider’s Examination	
Name ________________________________________________       Male      Female      Date of Birth ___________________
Medical History____________________________________________________________________________________
Pertinent Family History
Current Health Issues
YN
Allergies: Please list:  Medications __________________________Food ______________Other ____________
History of Anaphylaxis to _______________________Epi-Pen  Yes No
Asthma:     Asthma Action Plan  Yes No (Please attach)
Diabetes           Type I Type II
Seizure disorder: _____________________________________________________________________________
Other (Please specify) _________________________________________________________________________
Current Medications (if relevant to the student’s health and safety) Please circle those administered in school; a separate
medication order form is needed for each medication administered in school.
Physical Examination Date of Examination:	
Hgt:_________(______%) Wgt: _________(_______%)  BMI: __________(_______%)  BP: ____________
Check = Normal /If abnormal, please describe.)
   General___________________ Lunges____________________ Extremities___________________
   Skin______________________ Heart _____________________ Neurologic ___________________
   HEENT __________________ Abdomen __________________ Other _______________________
   Dental/Oral _______________ Genitalia ___________________
Screening:	
(Pass)  (Fail) (Pass)  (Fail) (Pass)  (Fail)	
Vision: Right Eye  Hearing: Right Ear Postural Screening:
Left Eye Left Ear               (Scoliosis/Kyphosis/Lordosis)
Stereopsis
Laboratory Results: Lead__________  Date _____________________  Other _______________________________________	
The entire examination was normal:
Targeted TB Skin Testing:   Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries, medical risk factors):
Date of PPD: _______; Results: ______mm.
Referred to evaluation to: ___________________________________________________     Low risk (no PPD done)
This student has the following problems that may impact his/her education experience:
       Vision Hearing Speech/Language Fine/Gross Motor Deficit
       Emotional/Social Behavior Other
Comments/Recommendations: __________________________________________________________________________________
Y N This student may participate fully in the school program, including physical education and competitive
sports. If no, please list restrictions: _____________________________________________________________________________
Y N  Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information
System Certificate or other complete immunization record.
Signature of Examiner Circle: MD, DO, NP, PA  DatePlease print name of Examiner
Group Practice Telephone
Address City State Zip Code	
Please attach additional information as needed for the health and safety of the student MDPH   11/30/04

Massachusetts Department of Public Health
CERTIFICATE OF IMMUNIZATION
Name:
Date of Birth:                / / Sex:     female male
If combination vaccine is administered, please indicate vaccine type (e.g. DtaP-Hib, etc.)
Vaccine Date/Vaccine Type Vaccine Date/Vaccine Type	
11
22	
Hepatitis B
(
e.g., HepB, HepB-Hib,
DTaP-HepB-IPV)	
33
1	
Haemophilus
influenzae type b
(
e.g., Hip, HepB-Hib,
DTaP-Hib)	
4	
21
3	
Measles, Mumps,
Rubella
(MMR)	2	
41
5	
Varicella
(Var)	2	
61	
Diphtheria,
Tetanus, Pertussis
(e.g., DTaP, DT,
DTaP-Hib,
DTaP-HepB-IPV, Td)	
7	
Hepatitis A
(HepA)	2	
11
2	
Pneumococcal
Polysaccharide
(PPV23)	2	
31	
Polio
(e.g., IPV,
DTaP-HepB-IPV)	
42
1	
Influenza
Inactivated
(Intramuscular) or Live
(Intranasal)	
3	
2
3	
Pneumococcal
Conjugate
(PCV7)	
4	
Other:	
Serologic Proof
of Immunity Check One Chickenpox History	
Test (if done) Date of test Positive Negative
Measles /     /
Mumps /     /
Rubella /     /
Varicella* /     /
Hepatitis B /     /	
* Must also check Chickenpox History box.Check the box if this person has a physician-
certified reliable history of chickenpox.
Reliable history may be based on:
•physician interpretation of parent/guardian
description of chickenpox
•physical diagnosis of chickenpox, or
•serologic proof of immunity	
I certify that this immunization information was transferred from the above-named individual’s medical records.
Doctor or nurse’s name (please print)Date:         /        /
Signature:
Facility name:
Certificate of ImmunizationJune 2004