Doctors use physical exam forms to document a patient's health history and any problems or symptoms they notice during the exam. There are many different types of physical exam forms, but all have the same purpose: to help doctors track a patient's health and diagnose any potential problems. Recently, a new fillable physical exam form was created that makes it easier for doctors to record information. This form can be filled out on a computer or tablet, which speeds up the documentation process. Additionally, it includes checkboxes so doctors can quickly identify any symptoms or problems. Overall, this is an excellent tool for doctor's offices everywhere.
If you'd like to find out some specific details in relation to the file you'll use, here is the data you should study before filling out the fillable physical exam form.
Question | Answer |
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Form Name | Fillable Physical Exam Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | Varicella, BMI, Meningococcal, Pertussis |
H511.336 (Rev. 9/2012) Page 1 of 4: STUDENT HISTORY
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Private or School |
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PHYSICAL EXAMINATION |
Bureau of Community Health Systems |
OF SCHOOL AGE STUDENT |
Division of School Health |
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Student’s name __________________________________________________________________________
Date of birth ________________________ |
Age at time of exam___________ |
PARENT / GUARDIAN / STUDENT:
Complete page one of this form before student’s exam. Take completed form to
appointment.
Today’s date___________________________
Gender: Male Female
Medicines and Allergies: Please list all prescription and
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Does the student have any allergies? No Yes (If yes, list specific allergy and reaction.)
Medicines |
Pollens |
Food |
Stinging Insects |
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Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.
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GENERAL HEALTH: Has the student… |
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YES |
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NO |
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1. Any ongoing medical conditions? If so, please identify: |
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Asthma Anemia |
Diabetes Infection |
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Other_________________________________________________ |
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2. Ever stayed more than one night in the hospital? |
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3. Ever had surgery? |
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4. Ever had a seizure? |
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5. Had a history of being born without or is missing a kidney, an eye, a |
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testicle (males), spleen, or any other organ? |
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6. Ever become ill while exercising in the heat? |
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7. Had frequent muscle cramps when exercising? |
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HEAD/NECK/SPINE: Has the student… |
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YES |
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NO |
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8. Had headaches with exercise? |
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9. Ever had a head injury or concussion? |
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10.Ever had a hit or blow to the head that caused confusion, prolonged |
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headache, or memory problems? |
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11. Ever had numbness, tingling, or weakness in his/her arms or legs |
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after being hit or falling? |
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12. Ever been unable to move arms or legs after being hit or falling? |
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13. Noticed or been told he/she has a curved spine or scoliosis? |
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14. Had any problem with his/her eyes (vision) or had a history of an |
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eye injury? |
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15. Been prescribed glasses or contact lenses? |
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HEART/LUNGS: |
Has the student... |
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YES |
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NO |
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16. Ever used an inhaler or taken asthma medicine? |
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17. Ever had the doctor say he/she has a heart problem? If so, check |
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all that apply: |
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Heart murmur or heart infection |
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High blood pressure |
Kawasaki disease |
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High cholesterol |
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Other:_____________________ |
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18. Been told by the doctor to have a heart test? (For example, |
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ECG/EKG, echocardiogram)? |
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19.Had a cough, wheeze, difficulty breathing, shortness of breath or |
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felt lightheaded DURING or AFTER exercise? |
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20. Had discomfort, pain, tightness or chest pressure during exercise? |
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21. Felt his/her heart race or skip beats during exercise? |
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BONE/JOINT: |
Has the student... |
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YES |
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NO |
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22. Had a broken or fractured bone, stress fracture, or dislocated joint? |
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23. Had an injury to a muscle, ligament, or tendon? |
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24. Had an injury that required a brace, cast, crutches, or orthotics? |
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25. Needed an |
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following an injury? |
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26. Had joints that become painful, swollen, feel warm, or look red? |
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SKIN: |
Has the student… |
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YES |
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NO |
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27. Had any rashes, pressure sores, or other skin problems? |
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28. Ever had herpes or a MRSA skin infection? |
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Has the student… |
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GENITOURINARY: |
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YES |
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NO |
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29. Had groin pain or a painful bulge or hernia in the groin area? |
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30. Had a history of urinary tract infections or bedwetting? |
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31. FEMALES ONLY: Had a menstrual period? |
Yes |
No |
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If yes: At what age was her first menstrual period? ______ |
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How many periods has she had in the last 12 months? ______ |
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Date of last period: ___________ |
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DENTAL: |
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YES |
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NO |
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32. Has the student had any pain or problems with his/her gums or teeth? |
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33. Name of student’s dentist: ________________________________ |
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Last dental visit: less than 1 year |
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SOCIAL/LEARNING: |
Has the student… |
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YES |
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NO |
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34. |
Been told he/she has a learning disability, intellectual or |
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developmental disability, cognitive delay, ADD/ADHD, etc.? |
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35. |
Been bullied or experienced bullying behavior? |
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36. |
Experienced major grief, trauma, or other significant life event? |
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37. |
Exhibited significant changes in behavior, social relationships, |
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grades, eating or sleeping habits; withdrawn from family or friends? |
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38. |
Been worried, sad, upset, or angry much of the time? |
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39. |
Shown a general loss of energy, motivation, interest or enthusiasm? |
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40. |
Had concerns about weight; been trying to gain or lose weight or |
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received a recommendation to gain or lose weight? |
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41. |
Used (or currently uses) tobacco, alcohol, or drugs? |
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FAMILY HEALTH: |
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YES |
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NO |
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42. |
Is there a family history of the following? If so, check all that apply: |
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Anemia/blood disorders |
Inherited disease/syndrome |
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Asthma/lung problems |
Kidney problems |
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Behavioral health issue |
Seizure disorder |
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Diabetes |
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Sickle cell trait or disease |
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Other________________________________________________ |
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43. |
Is there a family history of any of the following |
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problems? If so, check all that apply: |
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Brugada syndrome |
QT syndrome |
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Cardiomyopathy |
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Marfan syndrome |
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High blood pressure |
Ventricular tachycardia |
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High cholesterol |
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Other________________ |
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44. |
Has any family member had unexplained fainting, unexplained |
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seizures, or experienced a near drowning? |
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45. |
Has any family member / relative died of heart problems before age |
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50 or had an unexpected / unexplained sudden death before age |
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50 (includes drowning, unexplained car accidents, sudden infant |
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death syndrome)? |
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QUESTIONS OR CONCERNS |
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YES |
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NO |
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46. |
Are there any questions or concerns that the student, parent or |
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guardian would like to discuss with the health care provider? (If |
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yes, write them on page 4 of this form.) |
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I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.
Signature of parent / guardian / emancipated student_____________________________________________________ Date_______________
Adapted in part from the
Page 2 of 4: PHYSICAL EXAM
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STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes |
No |
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CHECK ONE |
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Physical exam for grade: |
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NORMAL |
*ABNORMAL |
DEFER |
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K/1 6 11 |
Other |
*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS |
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Height: |
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) inches |
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Weight: |
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) pounds |
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BMI: |
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) % |
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Pulse: |
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Blood Pressure: |
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Hair/Scalp |
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Skin |
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Eyes/Vision |
Corrected |
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Ears/Hearing |
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Nose and Throat |
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Teeth and Gingiva |
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Lymph Glands |
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Heart |
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Lungs |
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Abdomen |
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Genitourinary |
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Neuromuscular System |
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Extremities |
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Spine (Scoliosis) |
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Other |
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TUBERCULIN TEST |
DATE APPLIED |
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DATE READ |
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MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION
(Additional space on page 4)
Parent/guardian present during exam: Yes |
No |
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Physical exam performed at: Personal Health Care Provider’s Office |
School |
Date of exam______________20______ |
Print name of examiner _______________________________________________________________________________________________________
Print examiner’s office address___________________________________________________________________ Phone_______________________
Signature of examiner______________________________________________________________________ MD DO PAC CRNP
Page 3 of 4: IMMUNIZATION HISTORY
HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.
IMMUNIZATION EXEMPTION(S):
Medical |
Date Issued:___________ |
Reason: __________________________________________________ |
Date Rescinded:___________ |
Medical |
Date Issued:___________ |
Reason: __________________________________________________ |
Date Rescinded:___________ |
Medical |
Date Issued:___________ |
Reason: __________________________________________________ |
Date Rescinded:___________ |
NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.
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VACCINE |
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DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization |
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1 |
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5 |
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Diphtheria/Tetanus/Pertussis (child) |
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Type: DTaP, DTP or DT |
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Diphtheria/Tetanus/Pertussis |
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5 |
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(adolescent/adult) |
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Type: Tdap or Td |
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Polio |
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Type: OPV or IPV |
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Hepatitis B |
(HepB) |
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Measles/Mumps/Rubella (MMR) |
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Mumps disease diagnosed by physician |
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Date:__________ |
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Varicella: |
Vaccine |
Disease |
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Serology: (Identify Antigen/Date/POS or NEG) |
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i.e. Hep B, Measles, Rubella, Varicella |
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Meningococcal Conjugate Vaccine (MCV4) |
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Human Papilloma Virus (HPV) |
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Type: HPV2 or HPV4 |
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Influenza |
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6 |
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10 |
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Type: TIV (injected) |
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LAIV (nasal) |
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11 |
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12 |
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15 |
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Haemophilus Influenzae Type b (Hib) |
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Pneumococcal Conjugate Vaccine (PCV) |
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Type: 7 or 13 |
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Hepatitis A (HepA) |
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Rotavirus |
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Other Vaccines: (Type and Date)
Page 4 of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER)