Form PM 171 A Report of Health Examination for School Entry - California

Form PM171 A or the "Report Of Health Examination For School Entry" is a form issued by the California Department of Health Care Services.

Download a PDF version of the Form PM171 A down below or find it on the California Department of Health Care Services Forms website.

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State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
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
Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.
must be done after the child is 4 years and 3 months of age.
Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).
REQUIRED TESTS/EVALUATIONS
DATE (mm/dd/yy)
DATE EACH DOSE WAS GIVEN
Health History
VACCINE
First
Second
Third
Fourth
Fifth
______/______/______
Physical Examination
______/______/______
POLIO (OPV or IPV)
Dental Assessment
______/______/______
DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular]
Nutritional Assessment
pertussis) OR (tetanus and diphtheria only)
______/______/______
Developmental Assessment
______/______/______
MMR (measles, mumps, and rubella)
Vision Screening
______/______/______
HIB MENINGITIS (Haemophilus Influenzae B)
Audiometric (hearing) Screening
(Required for child care/preschool only)
______/______/______
TB Risk Assessment and Test, if indicated
______/______/______
HEPATITIS B
Blood Test (for anemia)
______/______/______
VARICELLA (Chickenpox)
Urine Test
______/______/______
OTHER (e.g., TB Test, if indicated)
Blood Lead Test
______/______/______
Other
______/______/______
OTHER
PART III
ADDITIONAL INFORMATION FROM HEALTH EXAMINER (
optional
)
and
RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN
I give permission for the health examiner to share the additional information about the health
RESULTS AND RECOMMENDATIONS
check-up with the school as explained in Part III.
Fill out if patient or guardian has signed the release of health information.
Please check this box if you do not want the health examiner to fill out Part III.
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)
Signature of parent or guardian
Date
Name, address, and telephone number of health examiner
Signature of health examiner
Date
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.
CHDP website:
www.dhcs.ca.gov/services/chdp
PM 171 A (09/07) (Bilingual)
State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
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
Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.
must be done after the child is 4 years and 3 months of age.
Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).
REQUIRED TESTS/EVALUATIONS
DATE (mm/dd/yy)
DATE EACH DOSE WAS GIVEN
Health History
VACCINE
First
Second
Third
Fourth
Fifth
______/______/______
Physical Examination
______/______/______
POLIO (OPV or IPV)
Dental Assessment
______/______/______
DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular]
Nutritional Assessment
pertussis) OR (tetanus and diphtheria only)
______/______/______
Developmental Assessment
______/______/______
MMR (measles, mumps, and rubella)
Vision Screening
______/______/______
HIB MENINGITIS (Haemophilus Influenzae B)
Audiometric (hearing) Screening
(Required for child care/preschool only)
______/______/______
TB Risk Assessment and Test, if indicated
______/______/______
HEPATITIS B
Blood Test (for anemia)
______/______/______
VARICELLA (Chickenpox)
Urine Test
______/______/______
OTHER (e.g., TB Test, if indicated)
Blood Lead Test
______/______/______
Other
______/______/______
OTHER
PART III
ADDITIONAL INFORMATION FROM HEALTH EXAMINER (
optional
)
and
RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN
I give permission for the health examiner to share the additional information about the health
RESULTS AND RECOMMENDATIONS
check-up with the school as explained in Part III.
Fill out if patient or guardian has signed the release of health information.
Please check this box if you do not want the health examiner to fill out Part III.
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)
Signature of parent or guardian
Date
Name, address, and telephone number of health examiner
Signature of health examiner
Date
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.
CHDP website:
www.dhcs.ca.gov/services/chdp
PM 171 A (09/07) (Bilingual)
State of California—Health and Human Services Agency
Department of Health Services
Child Health and Disability Prevention (CHDP) Program
INFORME DEL EXAMEN DE SALUD PARA EL INGRESO A LA ESCUELA
Para proteger la salud de los niños, la ley de California exige que antes de ingresar a la escuela todos los niños tengan un examen médico de salud. Por favor, pidale al examinador de
salud que llene este informe y entregelo a la escuela—este informe sera archivado por la escuela en forma confidencial.
PARTE I
PARA SER LLENADO POR EL PADRE/LA MADRE O EL GUARDIÁN
NOMBRE DEL NIÑO/NIÑA—Apellido
Primer Nombre
Segundo Nombre
FECHA DE NACIMIENTO—Mes/Día/Año
DOMICILIO—Número y Calle
Ciudad
Zona Postal
Escuela
PARTE II
PARA SER LLENADO POR EL EXAMINADOR DE SALUD
EXAMEN DE SALUD
REGISTRO DE INMUNIZACIONES
AVISO: Todas las pruebas y evaluaciones excepto el análisis
Aviso al Examinador: Por favor dé a la familia, una vez completado, o a la fecha, el Registro de Inmunización de California en
de sangre para el plomo deben ser hechas después de la edad
papel amarillo.
de 4 años y 3 meses.
Aviso a la Escuela: Por favor apunte las fechas de inmunización sobre el Registro de Inmunización de la escuela de California
en papel azul.
PRUEBAS Y EVALUACIONES REQUERIDAS FECHA(mm/dd/aa)
FECHA EN QUE CADA DOSIS FUE DADA
VACUNA
Primero
Segundo
Tercero
Quarto
Quinto
Historia de Salud
______/______/______
Examen Físico
______/______/______
POLIO (OPV o IPV)
______/______/______
Evaluación de Dientes
DTaP/DTP/DT/Td (difteria, tétano y [acellular] pertusis
[tos ferina]) O (tétano y difteria solamente)
Evaluación de Nutrición
______/______/______
Evaluación del Desarrollo
______/______/______
MMR (sarampión, paperas, rubéola)
HIB MENINGITIS (Hemófilo, Tipo B)
Pruebas Visuales
______/______/______
(Requerida para centros de cuidado para niños y centros
Pruebas con Audiómetro (auditivas)
______/______/______
preescolares solamente)
Evaluacion de Riesgo y prueba Tuberculosis*
______/______/______
HEPATITIS B
Análisis de Sangre (para anemia)
______/______/______
VARICELLA (Viruelas locas)
______/______/______
Análisis de Orina
OTRA (e.g. prueba TB, de ser indicado)
Análisis de Sangre para el plomo
______/______/______
Otra
______/______/______
OTRA
PARTE III
INFORMACIÓN ADICIONAL DEL EXAMINADOR DE SALUD (optional)
y
PERMISO PARA DIVULGAR (DISTRIBUIR) EL INFORME DE SALUD
RESULTADOS Y RECOMENDACIONES
Yo le doy permiso al examinador de salud para que comparta con la escuela la información adicional
Llene esta parte si el padre/la madre o el guardián ha firmado el consentimiento para divulgar
de este examen como es explicado en la Parte III.
(distribuir) la información de salud de su niño/niña.
Por favor marque esta caja si Ud. no desea que el examinador llene la Parte III.
El examen reveló que no hay condiciones que conciernen las actividades de los programas
escolares.
Las condiciones encontradas en el examen o después de una evaluación posterior que son de
importancia para la actividad escolar o física son: (por favor explique)
Firma del padre/madre o guardián
Fecha
*de ser indicado
Firma del examinador de salud
Fecha
Si su niño o niña no puede obtener el examen de salud llame al Programa de Salud para la Prevención de Incapacidades de Niños y Jovenes (Child Health and Disability Prevention Program)
en su departamento de salud local. Si Ud. no desea que su niño(a) tenga un examen de salud, puede firmar la orden (PM 171 B), formulario que se consigue en la escuela de su niño(a).
CHDP website:
www.dhcs.ca.gov/services/chdp
PM 171 A (3/03) (Bilingual)

Download Form PM 171 A Report of Health Examination for School Entry - California

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