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 longer than one year before your child’s entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _______________________

Student’s Name: _________________________________________________________________________________________________________________________
Last First Middle
Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________
Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________
Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Condition Yes Comments Condition Yes Comments

Allergies (food, insects, drugs, latex) Diabetes
Allergies (seasonal) Head injury, concussions
Asthma or breathing problems Hearing problems or deafness
Attention-Deficit/Hyperactivity Disorder Heart problems
Behavioral problems Lead poisoning
Developmental problems Muscle problems
Bladder problem Seizures
Bleeding problem Sickle Cell Disease (not trait)
Bowel problem Speech problems
Cerebral Palsy Spinal injury
Cystic fibrosis Surgery
Dental problems Vision problems

Describe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,
etc.):__________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly:
_______________________________________________________________________________________________________________________________________
Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No
Please provide the following information:
Name Phone Date of Last Appointment
Pediatrician/primary care provider
Specialist
Dentist
Case Worker (if applicable)

Child’s Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored

I, ______________________________________ (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 record.

Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______

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 COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section I
To be completed by a physician or his designee, registered nurse, or health department official.
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.
Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the
Medical Provider or Health Department Official in the appropriate box.

Student’s Name: Date of Birth: |____|____|____|

Last First Middle Mo. Day Yr.

IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

*Diphtheria, Tetanus (DT) or Td (given after 7 1 2 3 4 5

years of age)
*Tdap booster (6th grade entry) 1

*Poliomyelitis (IPV, OPV) 1 2 3 4

*Haemophilus influenzae Type b 1 2 3 4

(Hib conjugate)
*only for children <60 months of age
*Pneumococcal (PCV conjugate) 1 2 3 4
*only for children <60 months of age
Measles, Mumps, Rubella (MMR vaccine) 1 2

*Measles (Rubeola) 1 2 Serological Confirmation of Measles Immunity:

*Rubella 1 Serological Confirmation of Rubella Immunity:

*Mumps 1 2

*Hepatitis B Vaccine (HBV) 1 2 3

 Merck adult formulation used
*Varicella Vaccine 1 2 Date of Varicella Disease OR Serological Confirmation of Varicella
Immunity:
Hepatitis A Vaccine 1 2

Meningococcal Vaccine 1

Human Papillomavirus Vaccine 1 2 3

Other 1 2 3 4 5

Other 1 2 3 4 5

Other 1 2 3 4 5
I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child
*care or preschool
Required vaccineprescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III).

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____
Certification of Immunization 11/06

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Student’s Name: Date of Birth: |____ |_ ___|___ _|

Section II
Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be
detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________.

DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]

This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the
student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious
tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at
any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines
required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next
immunization due on __________________.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

Section III
Requirements

For Minimum Immunization Requirements for Entry into School and

Day Care, consult the Division of Immunization web site at
http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by
the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the
American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),
otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)).
(Requirements are subject to change.)

Certification of Immunization 03/2014

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 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: _______________________________________________ Date of Birth: _____/_____/__________ Sex: □ M □ F
Physical Examination
Date of Assessment: _____/_____/_______
1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment
Weight: ________lbs. Height: _______ ft. ______ in.
1 2 3 1 2 3 1 2 3
Health Assessment

Body Mass Index (BMI): ___________ BP____________

HEENT □ □ □ Neurological □ □ □ Skin □ □ □
 Age / gender appropriate history completed
Lungs □ □ □ Abdomen □ □ □ Genital □ □ □
 Anticipatory guidance provided
Heart □ □ □ Extremities □ □ □ Urinary □ □ □
TB Screening: □ No risk for TB infection identified □ No symptoms compatible with active TB disease
□ Risk for TB infection or symptoms identified
Test for TB Infection: TST IGRA Date:_______ TST Reading _____mm TST/IGRA Result: □ Positive □ Negative
CXR required if positive test for TB infection or TB symptoms. CXR Date: __________ □ Normal □ Abnormal
EPSDT Screens Required for Head Start – include specific results and date:
Blood Lead:___________________________________________ Hct/Hgb ____________________________________________

Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation
Emotional/Social
Developmental

Problem Solving
Screen

Language/Communication
Fine Motor Skills
Gross Motor Skills

 Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

1000 2000 4000 □ Referred to Audiologist/ENT □ Unable to test – needs rescreen
Hearing
Screen

R □ Permanent Hearing Loss Previously identified: ___Left ___Right

L
□ Hearing aid or other assistive device
 Screened by OAE (Otoacoustic Emissions): □ Pass □ Refer

 With Corrective Lenses (check if yes)

Stereopsis  Pass  Fail  Not tested  Problem Identified: Referred for treatment
Screen

Screen
Dental
Vision

Distance Both R L Test used:

20/ 20/ 20/  No Problem: Referred for prevention
 No Referral: Already receiving dental care
 Pass  Referred to eye doctor  Unable to test – needs rescreen

Summary of Findings (check one):

□ Well child; no conditions identified of concern to school program activities
Recommendations to (Pre) School , Child
Care, or Early Intervention Personnel

□ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________
_____________________________________________________________________________________________________________________________
___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________
Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epinephrine auto-injector □ other: ________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________
___ Medication. Child takes medicine for specific health condition(s). □ Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________

Health Care Professional’s Certification (Write legibly or stamp) □ By checking this box, I certify with an electronic signature that all of
the information entered above is accurate (enter name and date on signature and date lines below).
Name: _____________________________________ Signature: ________________________________________ Date: ____/_____/______

Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________

Phone: _______-_______-____________________ Fax: _______-_______-______________ Email: ______________________________________________

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