Page 1 is the student history, page 2 the physical exam, page 3 the immunization history and page 4 additional comments.
Page 1: complete the section with a check mark in the YES or NO column; circle questions you do not know the answer to.
Physical exam for grade: check one: K/1, 6, 11 or Other.
Immunization exemption: the parent/guardian must provide a written request to the school for a religious or philosophical exemption.
Immunization history: health care providers: please photocopy immunization history from student's record or insert information below.
| Question | Answer |
|---|---|
| Form Name | H511.336 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 12 min |
| Edition | Rev 9/2012 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | H511.336, H511 336, PA school physical form, Pennsylvania school physical examination, Private or School Physical Examination of School Age Student |
| Official source | H511.336 (Rev 9/2012), Pennsylvania Department of Health |
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