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1 REGISTRATION Student Name Date of Birth Country of Birth Documents Required by the Health Office: HEALTH HISTORY (Branchburg Township Form) CURRENT Physical Examination performed by the physician (9/6/2018 l st student day of school 2019) REQUIRED Immunizations DTaP/DTP 4 doses, with one dose given on or after the 4 th birthday, OR any 5 doses Polio 3 doses, with one dose given on or after the 4 th birthday, OR any 4 doses Measles 2 doses on or after the first birthday Rubella and Mumps 1 dose of each, on or after the first birthday Varicella 1 dose on or after the first birthday Hepatitis B 3 doses I have read and understand the requirements for my child to enter school. I understand that these documents must be presented to the school nurse no later than the first day of school, for my child to begin school. Parent/Guardian Signature Date address Thank you for your cooperation!
2 PK-5 PHYSICAL EXAMINATION RECORD -STUDENT INFORMATION- Name: Age: Date of Birth: Address: City/State/Zip: Home Phone: School: Teacher: Grade: Sex: Parent/Guardian s Full Name -PHYSICIAN OR PROVIDER INFORMATION- Height: Weight: Blood Pressure: / Pulse: bpm. Vision: R 20/ L 20/ Corrected: Y / N Contacts: Y / N Glasses: Y / N Hearing: Right ear 20dB Left ear 20dB Indicators Normal? Abnormal Findings/Comments (Circle One) Head/Neck Eyes/Sclera/Pupils Ears Nose/Mouth/Throat Heart: Murmurs/Rhythms Lungs: Auscultation/Percussion Chest Contour Skin Abdomen: Assessment (includes liver, spleen) Tanner Stage: Testes/Onset of Menses: Neck/Back/Spine: Range of Motion: Scoliosis: Upper Extremities Lower Extremities Neurological: Balance & Coordination: Romberg: Heel Walk: Tandem Walk: Nose Touch: Toe Walk: Hernia? If yes/possible, please explain) Existing health conditions: Most recent Immunizations/Dates: Medications currently in use: / Possible Recommendations/Limitations/Further examination: General Health: good fair poor EXAMINED BY: Fami ly Physician/Provider School Physician Physician s/provider s Stamp: MD DO NP PA Physician s/provider s Name: Phone: Fax: Address: City/State/Zip: Physician s/provider s Signature: Examination Date: PLEASE ATTACH RECORD OF IMMUNIZATIONS TO PHYSICAL EX AM INATIO N RECORD
3 HEALTH HISTORY TO PARENTS/GUARDIANS: Please provide the following information to help us understand the health status of your child. Child s Name Last First Middle Date of Birth Sex Parent s Name Father Mother Guardian(s) Siblings (Name & Birth Date) Name Birth Date Address: Phone # Last Physical Examination Date: 1. Developmental History: (Please indicate the age in months as accurately as possible) Creeping on all fours Toilet Training Sitting Alone Began to say single words Walking without assistance Began to say phrases Feeding self Began to say simple sentences 2. Behavioral History (Check any of the following which your child exhibits frequently) Nervousness Daydreaming Nightmares Shyness Trouble Sleeping Temper Tantrums Walking in sleep Nail biting Frequent fear/tension Frequent fighting Frequent crying Thumb/finger sucking Seperation anxiety Additional comments: 3. Medical History (Give approximate year or age): Asthma Diabetes Measles Bronchitis Seizures Rubella Pertussis Lyme Disease Mumps Pneumonia Eczema Chicken Pox Sinus Infections Encephalitis Gastrointestinal problems Strep Throat Meningitis Urinary tract problems Rheumatic Fever Mononucleosis Additional Comments:
4 4. Health Concerns (Please check any conditions pertaining to your child) Allergies (specify): Environmental Food Animal Insects Medications Headaches Frequent Colds Nosebleeds Mouth breathing Snoring Ear symptoms: Discharge from ears Turning head to hear Asking to have things repeated Hearing aid(s) Speech: Stuttering Lisp Immature Speech (baby talk) Eye symptoms: Squinting Styes or crusted lids Inflammation Muscle problems Excessive blinking Wears glasses Pain (frequent) Joints Muscular Other 5. Tuberculosis contacts? Yes No 6. Has your child had any of the following? Give details: Serious Accidents: Hospitalizations: Surgery: 7. Is your child taking any medication? (If yes, please specify reason and type of medication) 8. Has your child had any preschool experience? Where When I understand that state or federal law may prohibit the sharing of information contained in this form without prior approval of the parent or guardian. I hereby authorize the school nurse to share such information with teachers, aides, and administrators as may be required in her discretion to promote the health, safety, and general welfare of my child. Signature Parent/Guardian Date
5 REGISTRATION for PreK Student Name Date of Birth Country of Birth Documents Required by the Health Office: HEALTH HISTORY (Branchburg Township Form) CURRENT Physical Examination performed by the physician (9/6/ st student day of school 2019) REQUIRED Immunizations DTaP/DTP 4 doses Polio 3 doses Measles 1 dose on or after the first birthday Rubella and Mumps 1 dose of each, on or after the first birthday Varicella 1 dose on or after the first birthday Haemophilus influenzae B (Hib) 1 dose after the first birthday Pneumococcal - 1 dose after the first birthday Influenza* 1 dose - between September 1 and December 31, of each pre-school year. I have read and understand the requirements for my child to enter school. I understand that these documents must be presented to the school nurse no later than the first day of school, for my child to begin school. *The influenza documentation will be presented to the nurse in the fall. Parent/Guardian Signature Date address Thank you for your cooperation!
6 Branchburg School District Student Transportation Department 580 Old York Road Branchburg, N.J Fax Robert Cline, Transportation Supervisor Transportation Registration (Please print) DATE: NEW STUDENT CHANGE OF ADDRESS STUDENTS LAST NAME: FIRST NAME: MIDDLE NAME: HOME ADDRESS: ZIP CODE: HOME PHONE NUMBER: GENDER: M F DATE OF BIRTH: GRADE AS OF SEPTEMBER 2019 : SCHOOL STUDENT WILL BE ATTENDING: Branchburg Central MS Somerville High School Stony Brook School Whiton Elementary School PARENTS CONTACT INFORMATION OTHER THAN HOME PHONE NUMBER MOTHERS NAME: Cell Work FATHERS NAME: Cell Work EMERGENCY CONTACTS OTHER THAN PARENTS NAME: RELATIONSHIP CELL / LANDLINE PHONE # OFFICE USE ONLY: STUDENT ID#
In order to enter St. Catherine of Siena School, all NEW students (Grades 1 5) must have (1) a pre entrance physical and (2) completed immunizations.
ST. CATHERINE OF SIENA SCHOOL Middle States Accredited 39 E. Bradford Avenue, Cedar Grove, NJ 07009 Telephone 973 239 6968 Fax 973 239 1008 www.scs school cedargrovenj.org TO: Parents of NEW Students Grades
POPE JOHN PAUL II REGIONAL CATHOLIC ELEMENTARY CERTIFICATE OF IMMUNIZATION
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Name: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM. HEALTH SERVICES HISTORY and PHYSICAL
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Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.
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PEDIATRIC REGISTRATION FORM Please Print MALE FEMALE Name Birth / / LAST FIRST MI Address City State Zip Home Phone ( ) Parent s Work ( ) Social Security # Parent s Cell ( ) Email Address Parent s Marital
Pre-Admission Testing Questionnaire
Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered
Enrollment Application
Enrollment Application Please complete this application and return to: 11040 Colorado Blvd. Thornton, CO 80233 If you have any further questions, please contact us at: Fax: 303-920- 2147 Phone: 303-920-2142
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Feil & Oppenheimer Psychological Services
Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI 02806 401-245-4040 Fax: 401-245-1240 feiloppenheimer@gmail.com Adult Patient Questionnaire Name: Today's Date: Address: Home Phone:
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight: