AS4

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SECTION A - To be filled out by parent before physical examination.

NAME SEX: M F BIRTHDATE GRADE

ADDRESS

ILLNESS: Check and give approximate date your child had any of the following:		HANDICAPS: Check if your child has any problems with any of the following and give additional comments below:
Chicken Pox	Pohomyelitis		Allergies	Speech Difficulty
Diabetes	Rheumatic Fever		Asthma	Vision Difficulty
Ear Infection	Scarlet Fever		Behavior Problem	Fainting
German Measles	Tonsillitis		Epilepsy - seizures	Sleep Walking
Measles	Tuberculosis		Frequent colds	Menstruation
Mumps	Typhoid Fever		Hearing difficulty	Bed Wetting
Nephritis	Whooping Cough		Heart trouble	Constipation
Pneumonia	Other		Physical Handicaps	Night Terrors

ADDITIONAL INFORMATION ABOUT YOUR CHILD (include accidents, operations, etc. with dates):

ANY SPECIFIC ACTIVITIES TO BE ENCOURAGED RESTRICTED

*Fill in completely and accurately the dates your child received the following:

Vaccine Type		Primary Immunization Series					Boosters
	1st Dose Date		2nd Dose Date	3rd Dose Date	None	Date		Date
DPT
DT
Measles
Rubella
Mumps
M - R (Measles - Rubella)
M - R - M (Measles - Rubella - Mumps)
Polio (OPV or Trivalent)
Other (Specify)
Provider (where shots were given)
Date		Parent or Guardian's Signature					Relationship to Child

10/30/78 AS4

SECTION B - To be completed by examining physician. (PLEASE INDICATE CONDITION BY CODE AND GIVE DETAILS UNDER POSITIVE FINDINGS.)

Height Code: No defect, 1 - defect, correction or care not necessary

Weight 2 - defect, care or correction is necessary

POSITIVE FINDINGS: (Include any additional pertinent history)

RECOMMENDATIONS: (List any limitation of activity that child

Immunizations given at this visit

An intradermal tuberculin skin test should be performed on all children entering school.

Negative reactors should have tests repeated on successive school physical examinations.

Tuberculin Skin Test. Type Date Results

PHYSICIAN'S SIGNATURE ADDRESS PHONE

DATE

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