MASSACHUSETTS SCHOOL HEALTH RECORD
PRIVATE PHYSICIAN'S EXAMINATION

Child's
Name  ________________________________________________________Sex  ______ Birth Date _____________________________________

Address _________________________________________________________________  School _______________________________________
__________________________________________________________________________________________________
 
 IMMUNIZATION 
 Date 
 IMMUNIZATION 
 Date 
 IMMUNIZATION 
Date
    OTHER   TESTS
 DTP
  
 POLIO
       MMR (combined)       Date
            MMR 2  
TB 
  
          Other Immunization      Results  
            Hib      
            Hib      
            Hib       Date
 TD           Hib      LEAD  
Adult Type  
MEASLES
       Hepatitis B      Results  
   
MUMPS
       Hepatitis B      
Varivax  
RUBELLA
       Hepatitis B      

MEDICAL HISTORY   (give dates)

Accidents Ear Infections Measles Scarlet Fever
Allergy Encephalitis Meningitis Strep Throat
Chicken Pox Rubella Mumps Tonsillitis
Congenital Anomaly Heart Disease Operations Tuberculosis
Seizures Hernia Poliomyelitis Whooping Cough
Diabetes Kidney Disease Rheumatic Fever Other
_________________________________________________________________________________________________
PERTINENT FAMILY MEDICAL HISTORY
 
 
 
 
 
 
 
 

____________________________________________________________________________________________________________________
SUMMARY OF SIGNIFICANT TREATMENT PROGRAMS INCLUDING CURRENT MEDICATIONS, AND SUGGESTIONS FOR
PROGRAM ADJUSTMENT IF INDICATED
 
 
 
 
 
 
 
 
 

___________________________________________________________________________________________________________________

RECORD APPROVED BY DEPARTMENT OF EDUCATION AND THE MASS. DEPT. OF PUBLIC HEALTH

NOTE: Clip or staple this record to cumulative school health record

PRIVATE PHYSICIAN'S EXAMINATION

DATE........................................  Age ....................  BP .........../.......... Pulse .................... Hgt..................... Wgt....................

            Physical Development ....................

             Nutritional Status ....................

             Skin ....................

             Eyes .................... sclera ................... pupils ....................

                                          light & distance:  r .................... l ....................

                                           glasses ....................

             Ears .................... canals:  r ................... l ...................                       drums:  r ................... l ...................

             Nose ................... septum .................... turbinates .....................

             Mouth ..................lips .................... tongue .................... pharynx ....................

             Teeth ....................gingival..................

             Neck.....................mobility..................lymph nodes..................thyroid

             Throat...................shape......................symmetry....................

             Lungs...................

             Heart....................rate......................rhythm.................murmur....................

             Abdomen.....................liver....................spleen...................hernias....................

             Ano-Genital..................anus...................penis...................labia....................

                                                   testicles: r...................l....................

                                                   Tanner stage..................

             Spine...................

             Lower Extremities....................range of motion....................

                         development...................strength....................

             Upper Extremities....................range of motion...................

                         development...................strength..................

             Cranial Nerve...................I-XII...................

             Gait....................

              Coordination...................

            Lab Tests

            Hgb/Hct

                Other:

_________________________________________________________      ________________________________________________
Address                                                                       Date               Signature
 

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