History and Physical Examination Pg. 1 of 2

To Be Completed by the Health Care Provider

BORDENTOWN REGIONAL SCHOOL DISTRICT HEALTH SERVICES

Last Name: ______First Name: ______

Date of Birth: ______Gender: Male______Female ______

Medical History

Apgar Scores: 1 minute_____ 5 minute_____ Gestation: _____ weeks

Prenatal problems: ______

Disease History (Please indicate dates)

Allergies______Asthma______Otis Media______

Drug Sensitivities______Asthma Action Plan: ___yes ____no Rheumatic Fever______

Lyme Disease______Convulsive Disorder______Strep Infections______

Hepatitis______Diabetes______Mononucleosis______

Neuromuscular Disorder______Heart Disease______Heart Murmur______

Heart Defect______Cancer______Seizures______

Chicken Pox______Congenital Anomalies______Pneumonia______Other/Surgical Procedures (list dates):______

Is this child receiving any medications?

Immunization History (Please indicate the month, day and year or attach official immunization form)

Vaccine Type / 1st Dose / 2nd Dose / 3rd Dose / 4th Dose / 5th Dose
DPT, DT or Dtap
OPV or IPV
MMR
HIB
Hepatitis B
Varicella
Hepatitis A
Pneumococcal*
Influenza*

*Required for Preschool Students only

Country of Birth______Transferring into NJ from ______

If from country with high incidence of TB please test as per NJ Dept. of Health Tuberculosis Program guidelines. Tuberculosis testing for NJ Dept of Education TB Screening as follows:

Mantoux testing Date______Results______

IGRA Bloodwork Date______Results______

Chest X-Ray: Date______Results______

Please complete both sides of form

Student’s Name______

History and Physical Examination Pg. 2 of 2

To Be Completed by the Health Care Provider

Physical Examination

Height______Weight______Blood Pressure______

Eyes Ears

Nose Mouth and Teeth

Throat Tonsils/Adenoids

Lymph glands Skin

Heart

Murmur? Functional Pathologic

Any Restrictions?

Lungs

Musculoskeletal Scoliosis

Abdomen GI/GU

Hernia Nervous System

Speech

Growth and Development

Previous serious injuries, illness or deformities

Does this child have any physical needs or restrictions that would prevent or limit participation in school activities, including gym and sports activities? ______No ______Yes

Please Describe

Hearing Results

Db Level For each frequency, please indicate: P=Pass F=Fail

500Hz / 1000Hz / 2000Hz / 3000Hz / 4000Hz
Right:
Left:

Conclusion: (Please circle one): Pass Fail

Referral made for further testing: (Please circle one): Yes______No_____

Comments:

Vision Results

Right: 20 / _____ Left: 20 / _____ Both: 20 / _____

If vision screening over 20/32, was referral made: (Please circle one) Yes_____ No______

Physician’s Signature______Date of Exam______

Office Stamp: