HTML Preview Report of Health Examination for School Entry page number 1.
State of California—Health and Human Services Agency Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health
department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.
PM 171 A (09/07) (Bilingual) CHDP website: www.dhcs.ca.gov/services/chdp
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY
To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The
school will keep and maintain it as confidential information.
PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN
CHILD’S NAME—Last
First
Middle
BIRTH DATE—Month/Day/Year
ADDRESS—Number, Street
City
ZIP code
SCHOOL
PART II TO BE FILLED OUT BY HEALTH EXAMINER
HEALTH EXAMINATION
IMMUNIZATION RECORD
NOTE: All tests and evaluations except the blood lead test
must be done after the child is 4 years and 3 months of age.
Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.
Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).
REQUIRED TESTS/EVALUATIONS
DATE (mm/dd/yy)
VACCINE
DATE EACH DOSE WAS GIVEN
First
Second
Third
Fourth
Fifth
POLIO (OPV or IPV)
DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular]
pertussis) OR (tetanus and diphtheria only)
MMR (measles, mumps, and rubella)
HIB MENINGITIS (Haemophilus Influenzae B)
(Required for child care/preschool only)
HEPATITIS B
VARICELLA (Chickenpox)
OTHER (e.g., TB Test, if indicated)
OTHER
Health History
______/______/______
Physical Examination
______/______/______
Dental Assessment
______/______/______
Nutritional Assessment
______/______/______
Developmental Assessment
______/______/______
Vision Screening
______/______/______
Audiometric (hearing) Screening
______/______/______
TB Risk Assessment and Test, if indicated
______/______/______
Blood Test (for anemia)
______/______/______
Urine Test
______/______/______
Blood Lead Test
______/______/______
Other
______/______/______
PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional)
and
RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN
RESULTS AND RECOMMENDATIONS
Fill out if patient or guardian has signed the release of health information.
Examination shows no condition of concern to school program activities.
Conditions found in the examination or after further evaluation that are of importance to schooling or
physical activity are: (please explain)
I give permission for the health examiner to share the additional information about the health
check-up with the school as explained in Part III.
Please check this box if you do not want the health examiner to fill out Part III.
Signature of parent or guardian
Date
Name, address, and telephone number of health examiner
Signature of health examiner
Date