MASSACHUSETTS SCHOOL HEALTH RECORD
Health Care Provider’s Examination
Name ________________________________________  Male  Female    Date of Birth:___________________
Medical History _________________________________________________________________________________________
_______________________________________________________________________________________________________
Pertinent Family History

Current Health Issues
Y	N
	 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 ________________	 Lungs __________________	 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):  TB Test Type:  TST  IGRA  Date: ____________   Result: Positive Negative Indeterminate/Borderline   
Referred for evaluation to:  _________________________________________  Date:_______     Low risk (no TB test done)
This student has the following problems that may impact his/her educational 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     Date	                             Please print name of Examiner.			

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Group Practice				Telephone

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