MASSACHUSETTS SCHOOL HEALTH RECORD
School _________________________________________________________________  Female 		     	 Year of Graduation __________
Name										 Male      	DOB___/___/___ Primary Language Spoken (home)		
		Last			First		 	Middle						  Place of Birth ______________________
Street 								City/Town, State, Zip Code 								
Contact Information 						      		Emergency Contact Information
(1) Parent/Guardian:	(2) Parent/Guardian:		(1) Emergency Contact	(2) Emergency Contact	
Name & Mailing Address if different:

	Name & Mailing Address if different:		Name & Phone Number:	Name & Phone Number:	
Phone Numbers	Phone Numbers		Primary Care Provider	Dental Care Provider	
Home		Home		Name:	Name:	
Work		Work		Phone Number:	Phone Number:	
Cell		Cell		Health Insurance:
Allergies:	
FAX		FAX			

Primary Custody (if not joint) 						

General	Growth	Vision	Hearing	Postural	
		Preschool Certificate     Yes      No 				
School 
District	Year	Grade	Age	Ht.	Wt.	BMI	Left Eye	Right Eye	Stereopsis	Left Ear	Right Ear		
							Pass	Refer	Pass	Refer	Pass	Refer	Pass	Refer	Pass	Refer	Pass	Refer	
		Pre K																	
		K																	
		1																	
		2																	
		3																	
		4																	
		5																	
		6																	
		7																	
		8																	
		9																	
		10																	
		11																	
		12																	
Special Testing 	  Lead    Date ____/____/____       Tuberculin    1. Date of PPD ___/___/____;   result	 mm;  2. Date of PPD ___/___/____;   result	
		             Low risk (no PPD done)							
*School District on Waiver in accordance with MGL c71,s57 indicated by * in ‘Grade’ column.
•	Immunizations:  Please attach complete Massachusetts Immunization Certificate/record 
•	Due to software differences, this form may be used as a template for other formats.  (All information on this form must be included.)			April. 05