COMMONWEALTH OF VIRGINIASCHOOL 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 publickindergarten 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 theform. This form must be completed no earlier than one year before your child’s entry into school.
Name of School:Current Grade:

Student’s Name:

Last

First

Student’s Date of Birth: _____/____/______ Sex: _______

MiddleState or Country of Birth:

Main Language Spoken:

Student’s Address_____________________________________________ City_________________ State____________________ Zip Code_______________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: ______-______-______

Hospital Preference: ________________________________________________________
Child’s Health Insurance: None�FAMIS Plus (Medicaid) �FAMIS �

Private/Commercial/ Employer Sponsored� ______________________________

Box 1. Pre-Existing Conditions
Condition
Allergies (food, insects, drugs, latex)

Yes

Comments

Please list Life Threatening Allergies:

Condition
Diabetes: Type 1
Diabetes: Type 2Yes

Allergies (seasonal)
Asthma or breathing conditions
Attention-Deficit/Hyperactivity Disorder
Behavioral/Psych/ Social conditions
Developmental conditions
Bladder conditions
Bleeding conditions
Bowel conditions
Cerebral Palsy
Cystic fibrosis
Dental Health conditions

Insulin pump
Head injury, concussion
Hearing conditions or deafness
Heart conditions
Lead poisoning
Muscle conditions
Seizures
Sickle Cell Disease (not trait)
Speech conditions
Spinal injury
Surgery
Vision conditions

Comments

Describe any other important health-related information about your child (� Feeding tube , � Trach , � Oxygen support, � Hearing aids, � Dental appliance, � Wheelchair, Hospitalizations, etc.):

Box 2. Medications
List all prescription, emergency, over-the-counter, and herbal medications your child takes regularly (Home/ School):

Medication Name

1.
2.
3.
4.

DosageTime Administered ( Home/School)

Notes

Additional Medications (Name, Dose, Time Administered, Notes)

Check here if you want to discuss confidential information with the school nurse or other school authority.
TypePediatrician/primary care provider

NamePhoneYes

No

Please provide the following information:
Date of Last Appointment

Specialist
DentistCase Worker (if applicable)

I___________________________________(do) (do not ) authorize my child’s health care provider and designated provider of health care in the school setting todiscuss 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 Interpreter: _______________________________________________________________________Date_____/_____/______

MCH213G reviewed 10/2020

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COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization

Check if the student’sImmunization
Records are attachedusing a separate form
signed by HCP

Section I

See Section II for conditional enrollment and exemptions.
A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates ofadministration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as therecord is attached to this form. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. Pleasecontact your local health department for assistance with foreign vaccine records.
Student Name:

Date of Birth :Race (Optional):
IMMUNIZATION

Ethnicity:

Hispanic//

Sex:

Non-Hispanic

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

Diphtheria, Tetanus, Pertussis Vaccine (DTP,DTaP)

12345

Diphtheria, Tetanus (DT) or Tdap or TdVaccine (given after 7 years of age)

1

23

4

5Tdap Vaccine booster

1

Poliomyelitis Vaccine (IPV, OPV)

123

45

Haemophilus influenzae Type bVaccine (Hib conjugate)
only for children <60 months of age
Rotavirus Vaccine (RV)
only for children < 8 months of age

12341

23Pneumococcal Vaccine (PCV conjugate)
only for children <60 months of age

123Varicella Vaccine

12Date of Varicella Disease OR Serological Confirmation of VaricellaImmunity:

Measles, Mumps, Rubella Vaccine (MMRvaccine)12

Measles Vaccine (Rubeola)

12

Serological Confirmation of Measles Immunity:

Rubella Vaccine

12

Serological Confirmation of Rubella Immunity:

Mumps Vaccine

12

Serological Confirmation of Mumps Immunity:

Hepatitis B Vaccine (HBV) Merck adult formulation used

123

Hepatitis A Vaccine

12

Meningococcal ACWY Vaccine

12Meningococcal B Vaccine123Human Papillomavirus Vaccine (HPV)

123Influenza (Yearly)

12345Other

12345Other1234544Certification of Immunization

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school,
child care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III).
Signature of Medical Provider or Health Department Official:

TMCH213G reviewed 10/2020

Date (Mo., Day, Yr.): ___//____2Section II
Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.
This section must be attached to Part I Health Information (to be filled out and signed by parent).

Student’s Name: _______________________________________ Date of Birth: |____|____|_____|
Parent or Legal Guardian Name: _________________________________________
Parent or Legal Guardian Name: _________________________________________
Phone Number: _____________________________________MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration ofthe vaccine(s) designated below would be detrimental to this student’s health. The vaccine(s) is (are) specificallycontraindicated because (please specify):

DTP/DTaP/Tdap :[____]; DT/Td:[____]; OPV/IPV:[____]; Hib:[____]; PCV:[_____]; RV:[]; Measles :[_____];

Mumps:[____]; Rubella :[____]; VAR:[_____]; Men ACWY:[____]; Men B:[____]; Hep A:[_____]; HBV:[____]
This contraindication is permanent: [], or temporary [] and expected to preclude immunizations until: Date (Mo.,Day, Yr.): |_______|______|_______.
Signature of Medical Provider or Health Department Official:___Date (Mo., Day, Yr.):___/___/___RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student’sparent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious tenets orpractices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local
health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccinesrequired by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next
immunization due on.
Signature of Medical Provider or Health Department Official:

Date (Mo., Day, Yr.):||||

Section III Requirements
For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site athttps://www.vdh.virginia.gov/immunization/requirements/

Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee onImmunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP
recommendations (Ref. Code of Virginia § 32.1-46(a)).
(Requirements are subject to change.)

MCH213G reviewed 10/2020

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Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORTA qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry
into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vdh.virginia.gov/schoolage-health-and-forms/school-health-forms-and-action-plans/Student’s Name: _____________________________________

Health Assessment

Date of Assessment:
Weight://lbs. Height:

Body Mass Index (BMI):ft.

Date of Birth:

Sex:

Physical Examination

1 = Within normalin.

BPHEENTLungs
Heart Age / gender appropriate history completed
 Anticipatory guidance provided

1

2 = Abnormal finding

23

NeurologicalAbdomenExtremities

M □/ F/

3 = Referred for evaluation or treatment

123

1Skin
GenitalUrinary

2

3

Tuberculosis Screening

Check the box that applies:□ No risk for TB infection identified□ No symptoms compatible with

□ Risk for TB infection or symptoms identified
active TB disease
Test for TB Infection: TST IGRA Date:_______ __ TST Reading____ mm
TST/IGRA Result: □ Negative□ Positive
CXR required if positive test for TB infection or TB symptoms.
CXR Date:___________□ Normal □ Abnormal
EPSDT Screens Required for Head Start – include specific results and date:
Blood Lead:

Hct/Hgb
Assessment Method:

Vision Screen

Concern identified:

Referred for Evaluation

Emotional/Social
Problem Solving
Language/Communication
Fine Motor Skills
Gross Motor Skills
 Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
 Screened by OAE (Otoacoustic Emissions): □ Pass □ Referred1000

2000

4000

R

□ Referred to Audiologist/ENT□ Permanent Hearing Loss Previously identified:□ With Corrective Lenses (Check if yes)
Stereopsis □ Pass □ FailDistance
BothRL20/
20/
20/□ Unable to test – needs rescreen□ Left□ Right□ Hearing aid or another assistive device

L

Recommendations to (Pre) School ,Child Care, or Early Intervention
Personnel

Within normal□ Problems Identified: Referred for Treatment□ Not tested
Test used:

DentalScreenHearing
ScreenDevelopmental
ScreenAssessed for:□ No Problem: Referred for prevention□ No Referral: Already receiving dental care
□ Unable to perform□ Pass □ Referred to eye doctor □ Unable to test-needs rescreen

Summary of Findings (check one):□ Well child; no conditions identified of concern to school program activities□ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):_____________________________________________________________________________________________□ other:________________Allergy: □ food:_________□ insect:_______________ □ medicine:_________
Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epinephrine auto-injector □ other::_________Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)____Restricted Activity Specify::_______________________________________________________________________Developmental Evaluation □ Has IEP □ Further evaluation needed for: ______________________________________________Medication. Child takes medicine for specific health condition(s).
□ Medication must be given and/or available at school.
____Special Diet Specify: ________________________________________________________________________________________Special Needs Specify:____________________________________________________________________________________
Other Comments:____________________________________________________________________________________________

Health Care Professional’s Certification (Write legibly or stamp) □ By checking this box, I certify with an electronic signature that all of theinformation entered above is accurate (enter name and date on signature and date lines below).

Signature/Date:___________________________________
Name:________________________________________________________
Practice / Clinic:
Address:________________________________________________________
Phone:_______-________-___________________

MCH213G reviewed 10/2020

Fax: _______-________-__________ Email:__________________________________