Pennsylvania Health Form PDF Details

In the Commonwealth of Pennsylvania, the Pennsylvania Department of Health has designated a comprehensive form, known as H511.340 (8/2011), to streamline the process of monitoring and documenting the health status of school personnel. This meticulous form captures a wide array of essential health information beginning with basic patient identification details including name, contact information, and the patient's primary care provider. It extends to cover a detailed immunization history, specifying doses and booster shots for vaccines such as Diphtheria, Tetanus, Hepatitis B, and Measles, Mumps, Rubella among others. The form also places a significant emphasis on tuberculosis testing, outlining the procedure for reporting the test results and subsequent actions in the event of positive reactions. Additionally, it dives deep into identifying significant medical conditions across a broad spectrum including allergies, asthma, cardiac issues, and more, ensuring each is noted with the option to provide detailed explanations. The physical examination report section further scrutinizes various health aspects, from basic measurements to comprehensive evaluations of bodily systems, aiming to identify conditions that may affect the work role of the school personnel. Among its final stipulations, the form requires an acknowledgment by the personnel of the completeness and truthfulness of the provided information, coupled with a consent for the disclosure of this health data to the employing authority. This well-structured health form stands as a critical tool in managing and ensuring the well-being and fitness of individuals within the school environment.

QuestionAnswer
Form NamePennsylvania Health Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesschool personnel health record, pennsylvania school health form, pa school health form, pa school personnel health form

Form Preview Example

H511.340 (8/2011)

Position ____________________________

COMMONWEALTH OF PENNSYLVANIA

PENNSYLVANIA DEPARTMENT OF HEALTH

SCHOOL PERSONNEL HEALTH RECORD

I. Patient Information

Last Name

 

First

MI

Sex

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

Home Telephone

 

 

Work Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

Street

 

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Usual Source of Medical Care

 

Physician’s Name

 

Address

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact – Name

 

Relationship

 

Address

 

 

Telephone

 

II. Immunization History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter Month, Day, and Year Each Immunization was Given

 

 

 

 

VACCINE

 

 

 

DOSES

 

BOOSTERS & DATES

 

Diphtheria and Tetanus*

 

1.

 

2.

 

3.

 

4.

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

1.

 

2.

 

3.

 

 

 

 

 

Measles, Mumps, Rubella

 

1.

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other ________________

 

1.

 

Other _____________________

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Tetanus and Diphtheria are usually received in combined vaccines such as DTP, DtaP, DT, or Td

III. Required Tuberculosis Test Results (as per Regulations of the Department of Health

DATE APPLIED

ARM

METHOD

ANTIGEN

MANUFACTURER

SIGNATURE

 

 

 

 

 

 

DATE READ

RESULTS (mm)

SIGNATURE

For previously known/new positive reactors: _______________________________________________________________________

Chest X-ray:

Date: ____________ Results: _____________

Other: Date: _____________ Results: _______________

(Attach a copy of the report.)

 

(Attach a copy of the report.)

Preventive Anti-Tuberculosis Chemotherapy ordered:

No

Yes

Date: ______________

IF SIGNIFICANT REACTION WAS REPORTED, THE PHYSICIAN REPORT MUST STATE THAT THE APPLICANT IS FREE FROM CURRENT TUBERCULOSIS DISEASE OR IS UNDER ADEQUATE CHEMOTHERAPY FOR TUBERCULOSIS DISEASE:

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

IV. Significant Medical Conditions ()

 

Yes

No

If Yes, Explain:

Allergies

___________________________________________________________________

Asthma

___________________________________________________________________

Cardiac

___________________________________________________________________

Chemical Dependency

___________________________________________________________________

Drugs

___________________________________________________________________

Alcohol

___________________________________________________________________

Diabetes Mellitus

___________________________________________________________________

Gastrointestinal Disorder

___________________________________________________________________

Hearing Disorder

___________________________________________________________________

Hypertension

___________________________________________________________________

Neuromuscular Disorder

___________________________________________________________________

Orthopedic Condition

___________________________________________________________________

Respiratory Illness

___________________________________________________________________

Seizure Disorder

___________________________________________________________________

Skin Disorder

___________________________________________________________________

Vision Disorder

___________________________________________________________________

Other (Specify)

___________________________________________________________________

V. Report of Physical Examination ()

 

NORMAL

ABNORMAL

NOT

COMMENTS

 

EXAMINED

 

 

 

 

Height (inches) ______________

 

 

 

 

 

 

 

 

 

Weight (pounds) ______________

 

 

 

 

 

 

 

 

 

Pulse _____________

 

 

 

 

 

 

 

 

 

Blood Pressure ______________

 

 

 

 

 

 

 

 

 

Hair/Scalp

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

 

Eyes – Visual Acuity: R _____ L _____

 

 

 

 

Eyes – Color Vision

 

 

 

 

Ears – Hearing (dB) R _____ L _____

 

 

 

 

Nose and Throat

 

 

 

 

 

 

 

 

 

Teeth and Gingiva

 

 

 

 

 

 

 

 

 

Lymph Glands

 

 

 

 

 

 

 

 

 

Heart – Murmur, etc…

 

 

 

 

Lungs – Adventitous Findings

 

 

 

 

Abdomen

 

 

 

 

 

 

 

 

 

Genitourinary

 

 

 

 

 

 

 

 

 

Neuromuscular System

 

 

 

 

 

 

 

 

 

Extremities

 

 

 

 

 

 

 

 

 

Are there any special medical problems or chronic diseases which require restriction of activity, medication or which might affect his/her work role? If so, specify __________________________________________________________________________________

____________________________________________

__________________________________________________

___________________

Physician Name (Print)

Signature of Examiner

Date

______________________________________________________________________________________________________________________________

Physician Address

The statements and answers as recorded above are full, complete and true to the best of my knowledge and belief. I understand that any false or misleading statements may cause termination of my employment.

I authorize the physician or other person to disclose any knowledge or information pertaining to my health to the employing authority for whom this examination is performed.

_________________________________________

_____________________

Signature of Employee

Date

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1. The pa school health form requires particular information to be entered. Be sure the following blanks are finalized:

pa school physical form conclusion process explained (step 1)

2. Once the previous array of fields is done, you're ready to include the required particulars in VACCINE, Diphtheria and Tetanus, Hepatitis B, Measles Mumps Rubella, Other, Enter Month Day and Year Each, DOSES, BOOSTERS DATES, Other, Tetanus and Diphtheria are, DATE APPLIED, DATE READ, ARM, METHOD, and ANTIGEN so you can proceed to the 3rd stage.

Tips to prepare pa school physical form portion 2

3. The next part should be rather simple, For previously knownnew positive - all of these fields is required to be completed here.

pa school physical form writing process described (portion 3)

A lot of people frequently make some errors when completing For previously knownnew positive in this part. You need to double-check what you enter here.

4. This particular section arrives with the next few blank fields to look at: IV Significant Medical Conditions, Yes, If Yes Explain, V Report of Physical Examination, NORMAL, ABNORMAL, NOT, EXAMINED, COMMENTS, Height inches, Weight pounds, and Pulse.

Part no. 4 for filling in pa school physical form

5. Lastly, the following final portion is precisely what you should complete before closing the document. The blanks at issue are the following: Pulse, Blood Pressure, HairScalp, Skin Eyes Visual Acuity R L, Teeth and Gingiva, Lymph Glands Heart Murmur etc, Genitourinary, Neuromuscular System, Extremities, Physician Name Print, Are there any special medical, Signature of Examiner, Date, and Physician Address.

pa school physical form completion process described (portion 5)

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