Commonwealth Of Virginia School Entrance Health Form

Commonwealth of Virginia School Entrance Health Form

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part I – HEALTH INFORMATION FORM

State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no earlier than one year before your child’s entry into school.
Name of School*
Current Grade*
Student's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*
State or Country of Birth*
Main Language Spoken *
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Parent or Legal Guardian 1*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work or Cell
Please enter a valid phone number.Format: (000) 000-0000.
Name of Parent or Legal Guardian 2

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work or Cell
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work or Cell
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference
Child's Health Insurance

NoneFAMIS Plus (Medicaid)FAMISPrivate/Commercial/Employer Sponsored
Private/Commercial/Employer Sponsored
Box 1. Pre-Existing Conditions
Pre- Existing Conditions

Allergies (food, Insects, drugs, latex)Allergies (seasonal)Asthma or breathing conditionsAttention-Deficit/Hyperactivity DisorderBehavioral/Psych/Social ConditionsDevelopmental conditionsBladder conditionsBleeding ConditionsBowel ConditionsCerebral PalsyCystic FibrosisDental Health conditionsDiabetes: Type 1Diabetes: Type 2Insulin pumpHead injury, ConcussionHearing conditions or deafnessHeart ConditionsLead PoisoningMuscle conditionsSeizuresSickle Cell Disease (not trait)Speech ConditionsSpinal InjurySurgeryVision conditions
Allergies (food, Insects, drugs, latex) comments
Allergies (seasonal) comments
Asthma or breathing conditions comments
Attention-Deficit/Hyperactivity Disorder comments
Behavioral/Psych/Social conditions comments
Developmental conditions comments
Bladder conditions comments
Bleeding Conditions comments
Bowel Conditions comments
Cerebral Palsy comments
Cystic Fibrosis comments
Dental Health conditions comments
Diabetes: Type 1 comments
Diabetes: Type 2 comments
Insulin pump comments
Head injury, Concussion comments
Hearing conditions or deafness comments
Heart Conditions comments
Lead Poisoning comments
Muscle conditions comments
Seizures comments
Sickle Cell Disease (not trait) comments
Speech Conditions comments
Spinal Injury comments
Surgery comments
Vision conditions comments
Please list Life Threating Allergies
Describe any other important health-related information about your child (feeding tube, trach, oxygen support, hearing aid, dental appliances, wheelchair, hospitalizations, etc.)
Box 2. Medications

List all prescriptions, emergency, over-the-counter, and herbal medications your child takes regularly (Home/School)
1. Medication Name
Dose
Time Administered(home/school)
Notes
2. Medication Name
Dose
Time Administered(home/school)
Notes
3. Medication Name
Dose
Time Administered(home/school)
Notes
4. Medication Name
Time Administered(home/school)
Dose
Notes
Additional Medications (Name, Dose, Time Administered, Notes)
If you want to discuss confidential information with the school nurse or other school authority.

YesNo
Pediatrician/primary care provider name
Pediatrician/primary care provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last appointment

MonthDayYear
Date
Specialist name
Specialist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last appointment

MonthDayYear
Date
Dentist name
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last appointment

MonthDayYear
Date
Case worker name (if applicable)
Case Worker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last appointment

MonthDayYear
Date
I First Name* Last Name* do do not* authorize my child's health care provider and designated provider of health care in the school setting to discuss my child's health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child's school. When information is released from your child's record, documentation of the disclosure is maintained in your child's health or scholastic records.
Parent or Guardian*

First NameLast Name
Parent or Gaurdian Signature*
Date*

MonthDayYear
Date
Part II - COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Certification of Immunization Section I See Section II for conditional enrollment and exemptions. A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. Please contact your local health department for assistance with foreign vaccine records
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Race (Optional)
Ethnicity:

HispanicNon-Hispanic
Part III - COMPREHENSIVE PHYSICAL EXAMINATION REPORT

A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth.
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Should be Empty:

Commonwealth of Virginia School Entrance Health Form

Part I – HEALTH INFORMATION FORM

Box 1. Pre-Existing Conditions

Box 2. Medications

Part II - COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Part III - COMPREHENSIVE PHYSICAL EXAMINATION REPORT