Health Packet LEA BER INCLU YOUR EROO
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1 Health Packet Please complete and return to Holy Trinity School those pages in the packet required of the grade level your child will be entering in the school year. The state requires these forms to be filled out. The state will not let any student begin the school year unless an updated copy of their immunization records is received by the school. Please note that with both the Medical and Dental forms you may choose to have your private doctor/dentist complete the forms or you you must sign the permission slip to give the school nurse permission to do the physical exams. PLEASE REMEMBER TO INCLUDE YOUR CHILD'S NAME AND HOMEROOM!
2 Immunization records must be complete before any child may enter school on the first day. Children in all grades K 8 th grade need the following immunizations for attendance: 4 doses of diphtheria, tetanus, and acellular pertussis (1 dose on or after 4 th birthday) 4 doses of polio vaccine (4 th dose on or after 4 th birthday and at least 6 months after previous dose given) 3 doses of hepatitis B 2 doses of measles, mumps and rubella (MMR-dose #1 after the first birthday, dose #2 at least one month later) 2 doses of varicella (chicken pox) or written statement from physician/designee indicating month and year of disease or blood test proving history of having the disease *KINDERGARTEN STUDENTS: (in addition to the above) As of January 1, 2018, the ACHD is requiring proof of blood lead level testing of all Kindergarten students. All children are required to have their blood lead level tested prior to entry into kindergarten. This testing is usually done by the pediatrician at 1 or 2 years of age. Please send proof of the testing with a copy of the child's immunizations. Students entering Grade 7 (in addition to above vaccines) 1 dose of meningococcal conjugate vaccine (meningococcal B not accepted) 1 dose of tetanus, diphtheria and acellular pertussis (Tdap) (Whooping Cough) These requirements allow for medical reasons and religious beliefs. If your child is exempt from immunizations, he/she may be prohibited from attending school during a disease outbreak.
3 Medical Dear Parent/Guardian: The School Health Law requires physical examinations for children in Kindergarten and new students entering first grade. This grade was selected because it represents a critical period of growth and development in your child's life. You may also have received this form if your child does not have a physical in their medical file. If you elect, the physical examination will be done by our school physician, Huwaida Mansour, M.D. It is recommended that the examination be done by your child's physician since he/she can best evaluate your child's physical health and assist you in obtaining follow-up care. The school physical examination will be held during the school year. Physicals will be done in the morning. The parent may be present during the exam. If you have any questions, please feel free to call me. Kathleen R. Burik BSN, RN, CSN Certified School Nurse burikk@montourschools.com x4323 *************************************************************************************************** Please sign giving permission for the school physical examination. Complete the history page (attached) and return the entire form. Student's Name Homeroom Signature of Parent/Guardian Date **************************************************************************************************** If you prefer to have your private physician give the exam, sign here, complete the parent history page and return completed form after the exam. Signature of Parent/Guardian Please complete this form stating your preference of either a school or private exam and return to school asap.
4 l q,/20r2) Page 1 of 4. STUDENT HISTORY Plnerr / GunRotnr / Sruoenr: Private or School PHYSICAL EXAMINATION pennsylvania DEPARTMENT OF HEALTH Complete page one of this form before student's exam. Take completed form to OF SCHOOL AGE STUDENT Bureau of Community Health Sysiems Division of School Health appointment. Today's date Student's name Gender: Age at time of exam Date of birth nmale trfemale Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking: Does the student have any allergies? tr No tr Yes (lf yes, list specific allergy and reaction.) n Pollens! Medicines D Food tr Stinging lnsects Complete the following section with a check mark in the or NO column; circle questions you do not know the answer to. GEI{ERAL HEALTfl: HaS thg SIudAnI,,' 1. Any ongoing medical YE6 HO n Asthma n Anemia tl Diabetes tr GEl.tlTOUR.lliIARYi, lnfection 3. Ever had suroerv? a 32 Has the student had any pain d problems with his/her gums 6. Ever become ill while exercisino in the heat? 7. Had ftequent muscle cramps 3. Vvtren exercising? Ygs HEAEII{EOKTSPINE:'Hss f}6.sfrrdefif.., Ito 8. Had headaches with exercise? No Lastdentalvrsit: n lessthan 1 year E 1-2years E greaterthan2years SocIAULEtRNIHO: Has the student,,;. 35. Been bullied or experienced bullying behaviop tingling, or vueakness in his/her arms or legs after being hit or fallinq? 37. Exhibited signiflcant changes in behavior, social relationships, t*o YE8 iio::j NO grades, eating or sleeping habits; withdrawn from family or friends? 12 Ever been unable to move arms or legs atter being hit or falling? 38. Been worried, sad, upset, or angry much of the time? 13 Noticed or been told he/she has a curved spine or scoliosis? 39. Shown a qeneral loss of enerqy, motivation, interest or enthusiasm? 14 Had any problem with his/her eyes (vision) or had a history of an 40. Had concerns about u ight; been trying to gain or lose weight or received a recommendation to qain or lose \ eight? eye injury? 15 Been prescribed glasses or contact lenses? HEART/LUNGS: Has the studenl... HO Ever used an inhaler or taken asthma medicine? 41. Used (or currently uses) tobacco, alcohol, or drugs? F*MILYHEALTH: 42. ls there a family history of the following? lf so, check all that apply: tr lnherited disease/syndrome tr Anemia/blood disorders n Kidney problems n Asthma/lung problems 17 Ever had the doctor say he/she has a heart problem? lf so, check infection n tr Been told by the doctor to have a heart test? (For example, ECG/EKG, echocardiogram)? A Had discomfort, pain, tightness or chest pressure during exercise? Felt his/her heart race or skip beats during exercise? Has the student... tr D Seizure disorder tr Sickle cell trait or disease Brugada syndrome tr QT syndrome tr Marfan syndrome tr Ventriculartachycardia n Other 44. Has any family member had unexplained fainting, unexplained seizures, or experienced a near drowning? 23 Had an injury to a muscle, ligament, or tendon? 45. Has any family member / relative died of heart problems before age 24 Had an iniury that required a brace, cast, crutches, or orthotics? 50 or had an unexpected / unexplained sudden death before age 50 (includes dro\ /ning, unexplained car accidents, sudden infant death syndrome)? Needed an x-ray, MRl, CT scan, injection, or physical therapy followinq an iniury? 26 Had joints that become painful, s\ ollen, feel warm, or look red? T/. Had any rashes, pressure sores, or other skin problems? issue n Cardiomyopathy n High blood pressure n High cholesterol xo 2- Had a broken or fractured bone, stress fracture, or dislocated joint? the sludent.,, Diabetes 43. ls there a family history of any of the following heart-related problems? lf so, check all that apply: Mleeze, difficulty breathing, shortness of breath or felt liohtheaded DURTNG or AFTER exercise? z. Behavioral health Other 19 Had a cough, ':.:Has 36. Experienced maior qrief, trauma, or other significant life event? 11. Ever had numbness, E Heart murmur or heart apply: pressure tr Kawasaki disease cholesterol I Other: NO Name of student's dentist the head that caused confusion, prolonged headache, or memory problems? 10 Ever had a hit or blow to all that n High blood E Hioh or teeth? 34. Been told he/she has a learning disability, intellectual or developmental disabilitv, coqnitive delay, ADD/ADHD, etc.? 9. Ever had a head injury or concussion? $KlN: tr Yes tr - DEHTAL: testicle (males), spleen, or any other organ? 8. period? _ 5. Had a history of being born without or is missing a kidney, an eye, BONBJoINT: i.ro _ 4. Ever had a seizure? a ONLY: Had a menstrual lf yes: At what age was her flrst menstrual period? How many periods has she had in the last 12 months? Date of last period: 31. FEMALES 2. Ever stayed more than one night in the hospital? 18. $fajdenf..' O. Had a history of urinary tract infections or bed\^etting? Other '16 #as# 29. Had groin pain or a parnful bulge or hemia in the groin area? conditions? lf so, please identify: HO QUE$TlOfl S on colrlgern$ 46. Are there any questions or concems that the student, parent or Ever had herpes or a MRSA skin infection? guardian would like to discuss with the health care provider? (ll yes, Wlte them on page 4 of this form.) I hereby certify that to the best of my knowledge atl of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers. Signatureofparent/guardian/emancipatedstudentDate Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.
5 Page2 of 4'. PHYSICAL EXAM $TUDE-ilT'$ HEALTH Hi$fOnY (pege i of thi$form) REVIEWED PRICIR TO PERFOMING EXAMINATIONT Yee E :..,,tlo.,,il Physical exam for grade: K/1n 6fl 11n other n "ABNORMAL FINDINGS / NECOTVITVIENDATIONS / REFERRALS TUBERCULII.I TEST DATf AFPLIED DATE READ RE$uLT/FOLLOW-UP MEDICALCOI.IDITIONEON0HNOXlcSISTASESWHIEfi REQUIRE MEDIDA:TIONI RESTRICTION OT ACT VITY, OR WHICH MAY AFFECT EDUCAfIOI'I (Additional space on page 4) ParenUguardian present during exam: Yes I No E Physical exam performed at: Personal Health Care Provider's Office E School f] Date of exam- 20 Print name of examiner Print examiner's office address Signature of examiner MDtr DON PACN CRNPN
6 Page 3 of 4: IMMUNIZATION HISTORY HEALTH CARE PROVIDER$: Ptease phqtocopy immunization history from student's record - OR - inseft information below. TMMUNTZATTON EXEMPTTON(S): Medical E Date lssued:_ Reason: Medical I Date lssued:_ Reason: Medical n Date lssued: Reason. Date Rescinded: Date Rescinded: Date Rescinded: NOTE: The parenuguardian must provide a written request to the school for a religious or philosophical exemption. VA6CII{E DOOUMHNT: (1) Type of vaccine; {2} Date (month/day/yeai} for each immunization Diphtheria/Tetan us/pertussis (child) Type: DTaP, DTP or DT Diphtheria/Tetanus/Pertussis (adolescenuadult) Type: Tdap or Td Polio Type: OPV or IPV Hepatitis B (HepB) MeaslesiMumps/Rubella (MMR) Mumps disease diagnosed by physician! Date: Varicella: Vaccine E Disease fi Serology: (ldentify Antigen/Date/POS or NEG) i.e. Hep B, Measles, Rubella, Varicella Meningococcal Conjugate Vaccine (MCV4) Human Papilloma Virus (HPV) Type: HPV2 or HPV4 lnfluenza Type: TIV (injected) LAIV (nasal) Haemophilus lnfluenzae Type b (Hib) Pneumococcal Conjugate Vaccine (PCV) Type: 7 or 13 Hepatitis A (HepA) Rotavirus Other Vaccines: (Type and Date)
7 page 4 of 4.. ADDITIONAL COMMENTS (Prnem / GuaRoter / SruoElr / HerurH Crne Pnouoenl
8 Dental Dear Parent/Guardian: The School Health Law requires dental examinations for children in grades Kindergarten, 1 (new students), 3, and 7. These grades were selected because they represent critical periods of growth and development in the child's life. If you elect, our school dentist, Andrew R. Berg, D.D.S., will perform the dental examination. It is recommended that the examination be completed by your child's dentist since he/she can best evaluate your child's dental health and assist you in obtaining necessary treatment and corrections. A private dental exam will be accepted if completed within the last 12 months. The school dental examinations are scheduled in February. If you have any questions or concerns, please feel free to call me. Kathleen R. Burik BSN, RN, CSN Certified School Nurse burikk@montourschools.com x4323 *********************************************************************** Please sign giving permission for the dental examination. Student's Name Homeroom Signature of Parent/Guardian Date ************************************************************************ If you prefer to have your private dentist complete the exam, please sign here and return this form and submit the attached private dental form once completed by the dentist. Signature of Parent /Guardian Please return this form noting your preference of a school or private exam as soon as possible.
9 r-r5r4.027 (08i2011) CON,I M ONWEALTFI OF' PENN SYLVANIA DEPARTMENT OF I{EALTI.I PRIVATE DENITIST REPORT OF DENTAI, EXANTINATION OF A PUPIL OF SCHOOL AGE NAME OF SCHOOL I]ATE NAME OF CHILD Last Middle AGE SEX nn MF' GRADE SECTION/ROOM ADDI{E,SS No. and Street City or Post Ollice Borough,iTorvnship County Siate zip REPORT OF EXAL,{INATION TOOTH CHART UPPER LOWER RIGHT I B 32 3I )ta T S 6 C 27 R. 7 l) 8 E 26 o 25 P I 9 F l0 G N ll FI 22 M LEFT t2 t3 t4 l5 t6 j 21 L 2t) K t9 t8 11 U Lower UPPER U LOWER Is The Child Under Treatment? Yes n Non Lowe Treatrnent Completecl Yes tr Non Date of Dental Examination Signature of Dental Examiner Print Name of Dental Examrner Address
10 HOLY TRINITY CATHOLIC SCHOOL CONFIDENTIAL HEALTH HISTORY Name Birth Date Grade Does your child have any of the following conditions? (Check all that apply and please explain below) Allergies: Environmental Food Insect Bites Medications Skin Conditions Severe Allergy Anaphylactic Shock Emergency Meds needed* Yes No Name of Medications *For any severe allergy, a FAAP (Food and Anaphylaxis Allergy Action Plan) must be completed (form on website) Asthma: Emergency Meds Birth/Prenatal (Note any abnormal condition) Heart: Congenital Defect Murmur Rheumatic Fever Any restrictions? Seizures Type: Date of last seizure Medication ADD/ADHD Anxiety Arthritis Behavior/ Emotional: Explain Blood Disorder Broken Bones Chicken Pox Date of illness: Diabetes: Date of diagnosis: Medications Fainting Gastrointestinal Bowel Control Head Injury/Concussion: Hearing Mobility Operations: Speech Tuberculosis Urinary Tract : Incontinence Infections Bedwetting Vision Has your child ever been tested at: (Check all that apply**) Children s Hospital D.T. Watson Western Psychiatric Hospital Laughlin Child Center DART and/or have an IEP Other **If so, please provide the district with copies of the evaluation so we may best serve your child Please list any medications, additional medical care, special needs or other information about your child that you feel is important. Parent/Guardian Signature Date
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