2009-2010 Child Health Record

Last Name:		First:	MI:	Sex: c M c F
Date of Birth:
(mm/dd/yy)
Child’s Doctor:	Name: __________________________________________________________________ Address: ________________________________________________________________ Phone: __________________________________________________________________

n n n n n n n n n n n n n n n n n

(to be completed by physician)

Physical Examination:

I certify that ____________________________ is in good health and physically able to take part in the Preschool program.

(name of child)

Results and recommendations: ___________________________________________________________________________

List any health conditions the school should be informed of (i.e., allergies, dietary restrictions, vision or hearing
difficulties, seizures, etc.): _______________________________________________________________________________

____________________________________________ __________________________

Physician’s Signature (required) Date of exam

Immunizations:

Please provide a copy of your child’s current immunization schedule. The following are required:

Immunization	# of Doses required	Immunization	# of Doses required
DTP/DTaP/DT/Td	5	Hep A	2
MMR	2	Hib	4*
OPV/IPV	4	Varicella	1
Hep B	3	Pneumoccocal	4

*Certain manufacturers only require 3 rounds. Consult your pediatrician for verification.

* PLEASE ATTACH YOUR CHILD’S IMMUNIZATION RECORDS *

1201 Lavaca St., Austin, TX 78701 | Ph: (512) 478-5709 | Fax: (512) 478-9365

Screener / Physician: You may use the forms below or attach your own.

Vision Screening: (required for 4 & 5 year olds)

This is a basic screening test that indicates common visual abnormalities and is not a substitute for a complete eye examination by a doctor of ophthalmology.

			Comments
Distance acuity:	R: __________	L: ___________
Near muscle balance:	c Pass	c Fail
Far muscle balance:	c Pass	c Fail
Farsighted lens:	c Pass	c Fail
Chart Used:	c Snellen	c HOTV
Corrective lens worn:	c Yes	c No

c This is a normal test for this student’s age.

c Failed screening. This student needs a complete visual exam from a doctor of ophthalmology.

n n n n n n n n n n n n n n n n n

Hearing Screening: (required for 4 & 5 year olds)

This is a basic screening test that identifies a hearing loss that may affect daily activities.

	R	L	Comments
25db
500 Hz
1000 Hz
2000 Hz
4000 Hz

c This is a normal test. No further testing is necessary.

c Failed screening. This student needs a complete ear exam from a physician.

_________________________________________ __________________

Screener / Physician signature Date