This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4) Student Name: Last
First
Address: Street
Middle Apt #
City
State
Date of Birth
Sex
Zip Code
Home Phone
PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript). IMMUNIZATIONS Please enter dates in MM/DD/YYYY format Hepatitis B Diphtheria-Tetanus-Pertussis DTP/DTaP
Check if DT
Check if DT
Check if DT
Check if DT
Check if DT
Pneumococcal Conjugate PCV Polio Haemophilus Influenzae Type B Hib Measles-Mumps-Rubella MMR Varicella
Student has history of varicella disease
Tetanus-Diphtheria-Pertussis TdaP/Td
Check if Td
Check if Td
Check if Td
Rotavirus Hepatitis A Meningococcal HPV Immunization Exemption: Medical Hep B DTaP PHYSICAL EXAMINATION
PCV
Religious Polio
Hib
Date of PE _____/_____/_____
MMR
Varicella
Height ___________
Td/Tdap
Rotavirus
Weight___________
Hep A
Mening
HPV
BP____________
Please note any health problem, chronic health condition or disability that may affect behavior or health at school: ASTHMA: No Yes
Significant Systems Findings: __________________________________________________________________________________________________________________ ALLERGIES: No
Treatment Plan: ____________________________________________________________________________________________________________________________ MEDICATION (REQUIRED AT SCHOOL): No
Other medication(s) that may affect behavior or health at school: _____________________________________________________________________________________ RESTRICTIONS: Can participate in physical education: Can participate in sports: LEAD SCREENING (Required for children < 6 years of age only) Student is in compliance with lead screening requirements: Yes No TUBERCULOSIS (If required by school district) Date of TB test: HEALTH CARE PROVIDER SIGNATURE: PRINT NAME:
Fully
With limitation _____________________________________________________
Fully
With limitation _____________________________________________________
SCOLIOSIS SCREENING Yes No
VISION SCREENING (Children entering Kindergarten) Passed screening Screened and referred for comprehensive exam Referred for comprehensive exam, but not screened Screening Date: Comprehensive Exam Date:
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. New RI Physical Form 7-10.pdf. New RI Physical Form 7-10.pdf. Open. Extract. Open with. Sign In. Main menu.
Student has history of varicella disease. Tetanus-Diphtheria-Pertussis. TdaP/Td Check if Td. Check if Td Check if Td. Rotavirus. Hepatitis A. Meningococcal. HPV.
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Page 1 of 1. Confidential â for GFL Sports, Inc. ONLY Revised 1-18. GFL FOOTBALL AND CHEERLEADING. PHYSICAL EXAMINATION FORM. Name of Association: Year 2018. I certify that I examined. recommend him/her to be. physically able to compete in football
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... information you feel may be helpful in considering your application, i. e. honors, awards,. activities, technology skills or professional development activities.