# School Health Forms

## Student Information
- **Student Name:** _________________________
- **Date of Birth:** _________________________
- **Grade:** _________________________
- **School:** _________________________

## Physical Examination Report
- **Date of Exam:** _________________________
- **Height:** _________________________ **Weight:** _________________________
- **Blood Pressure:** _________________________
- **Vision:** ☐ Normal ☐ Needs Correction ☐ Other: _________________________
- **Hearing:** ☐ Normal ☐ Needs Further Testing ☐ Other: _________________________

## Immunization Record
- **DTaP:** Date: _________________________ ☐ Up to date ☐ Needs update
- **MMR:** Date: _________________________ ☐ Up to date ☐ Needs update
- **Varicella:** Date: _________________________ ☐ Up to date ☐ Needs update
- **Hepatitis B:** Date: _________________________ ☐ Up to date ☐ Needs update
- **IPV:** Date: _________________________ ☐ Up to date ☐ Needs update

## Health Conditions
- **Chronic Conditions:** _________________________
- **Medications:** _________________________
- **Allergies:** _________________________
- **Activity Restrictions:** _________________________

## Emergency Information
- **Emergency Contact 1:** _________________________
- **Phone:** _________________________
- **Relationship:** _________________________
- **Emergency Contact 2:** _________________________
- **Phone:** _________________________
- **Relationship:** _________________________

## Physician Information
- **Physician Name:** _________________________
- **Practice:** _________________________
- **Phone:** _________________________
- **License Number:** _________________________

## Authorization
☐ I authorize the release of this health information to the school
☐ I understand this information will be used for school health services
☐ I will notify the school of any changes in my child's health status

**Parent/Guardian Signature:** _________________________
**Date:** _________________________

**Physician Signature:** _________________________
**Date:** _________________________

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*Rose Pediatrics Care - School Health Forms*