Student Health Card and Physical Examination Record - 04.03.2017 - FINAL
Student Health Card and Physical Examination Record - 04.03.2017 - FINAL
Student Health Card and Physical Examination Record - 04.03.2017 - FINAL
IMPORTANT: PARENTS MUST FILL OUT THE INFORMATION REQUESTED BELOW (IN PRINT) AND COMPLETE PAGES
2-3 OF THIS FORM. PAGE 4 MUST BE COMPLETED BY A LICENSED PHYSICIAN NO MORE THAN 12 MONTHS BEFORE
EXPECTED START DATE.
NOTE: Please notify the Admissions Office of any changes in phone numbers or contact persons.
Health History:
Please indicate if your child has had any of the following conditions. If the answer is yes to any, please give details below.
Tuberculosis Psoriasis
Fainting Spells Vitiligo
Atopic
ADD / ADHD
Dermatitis
Heart Disorder Impetigo
Urinary Other Illness/Condition
Disorder
Epilepsy
Describe:
If the answer to any of the above is YES, please see Tuberculosis Screening Section on page 4.
AUTHORIZATION
I give consent for my child to receive the following:
*NOTE: If NO to 1,2, and/or 3 above, the student may not enter school until a meeting is set with the School Health Clinic.
I hereby authorize the ISM designated Dentist to give the following dental treatment to my child, as the need arises:
Permission is hereby given for emergency measures to be initiated in case of accident or sudden illness with the
understanding that I will be notified as soon as possible.
I certify that all information given on this card is complete and correct.
I acknowledge that it is my responsibility to inform the ISM School Health Clinic of any changes in my childs
health, physical condition or medical needs.
Parents Name:
Height (cm) ______ Weight (kg) ______ Blood Pressure ______ Vision: R ______ L ______ Both ______ Blood type ______
Please review the following areas: Normal Findings DESCRIPTION (Attach additional sheets if necessary)
1. Head, Eyes, Ears, Nose, Throat
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Hernia
6. Genitourinary
7. Musculoskeletal
8. Metabolic/Endocrine
9. Neuropsychiatric
10. Skin
11. Mammary
Describe Findings:
Comments:
An ECG (12-lead resting electrocardiogram) is REQUIRED for all new students entering Grade 6 and above.
Diagnosis: q age appropriate ECG q further cardiological diagnostic required q pathological heart condition
Findings:
If further tests are required, please submit findings along with this form.
Remarks:
TUBERCULOSIS SCREENING
ATTENTION HEALTH CARE PROVIDER: Please refer to the Tuberculosis Screening Checklist on page 3. If the answer to
any of the questions is YES, proof of PPD skin test is required. If the student has a history of a positive PPD test or if PPD
result is positive a chest x-ray is REQUIRED. PPD and/or chest x-ray must be done within one calendar year prior to
admittance. History of BCG vaccination does not exclude the student from PPD skin testing.
CHEST X-RAY
Required for those with a positive skin test, history of a positive skin test or history of tuberculosis infection.
Date of x-ray: _______________ Result of x-ray: ________________
If negative CXR and positive PPD, did student complete a course of treatment? YES NO
If yes, how many months did the treatment last? (# of months)