POCONO MOUNTAIN SCHOOL DISTRICT
|POCONO MOUNTAIN SCHOOL DISTRICT |
|PRIVATE PHYSICIAN’S REPORT OF PHYSICAL EXAMINATION |
| |
|Name | | | | |
| | |Male / Female | |Date of Birth |
|IMMUNIZATION STATUS: (asterisk denotes required vaccines for school attendance) |
| |
|*Required for attendance in schools in Pennsylvania ALL grades K through 12. PA LAW now states students will need 4 doses of tetanus, diphtheria, & acellular |
|pertussis, 4 doses of Polio, 2 doses MMR, 3 doses Hepatitis B, & 2 doses Varicella. |
| |
|For entry into 7th & 12 Grade: |
|1 dose of TdaP & Meningococcal for entry into 7th grade |
|2nd dose Meningococcal for entry into 12th grade. |
|DIPHTH-TETANUS (PERTUSS.) |POLIO |OTHER |
|Dose Date |Dose Date Given |First MMR & varicella must be given after age 12 months. |
|Given | | |
|*1st |*1st |*MMR 1st 2nd |
|*2nd |*2nd |*Varicella 1st 2nd |
|*3rd |*3rd |*Measles 1st 2nd (Usually given |
|*4th |*4th |*Mumps 1st 2nd as |
|Booster | 5th |*Rubella 1st 2nd MMR) |
|**Tdap AFTER AGE 11yr |**Meningococcal Vaccine | |
|________________________ |(Menactra) | |
| |1st _______________________ | |
| |2nd ___________AFTER AGE 16 yr | |
| |***Hepatitis B 1st |
|*PLEASE NOTE: The 4th DtaP & Polio must be age 4 yrs. or older per PA Law | 2nd |(Min. 24 days after #1) |
| | 3rd |(Min. 52 days after #2) |
| | | | |
|MEDICAL HISTORY: |
|Childhood diseases | |
|Allergies | |Operations | |
|Serious Illnesses or Accidents | |
| | |
| |
|REPORT OF EXAMINATION: (Elaborate on positive findings) |
|Height Weight |Lungs |
|Skin |Heart |
|Eyes |Blood Pressure Pulse Rate |
|Ears |Abdomen |
|Nose/Throat |Genitalia |
|Teeth/Gingiva |Nervous System |
|Glands |Posture |
|**Scoliosis |Musculo Skeletal System |
|** Results required for grade 6 physical per PA Law | |
| | |
|Is the child under treatment? |
| |
| | |
| | | |
|Date | |Signature of Examining Physician |
| | | |
| | | |
|Physician’s Phone Number | |Physician’s Address |
| | | |
|PLEASE RETURN PRIVATE MEDICAL FORM THE FIRST DAY OF SCHOOL or |
|UPON NURSE’S REQUEST or MAIL TO: |
| | | |
| |Pocono Mountain West High School Nurses | |
| |181 Panther Lane, Pocono Summit, PA 18346 | |
| |FAX 570-839-5782 | |
| | | |
| | | |
|Physical Exam Form | |Revised 3/26/13 |
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