KEARNY SCHOOLS MEDICAL DEPARTMENT MEDICAL REGISTRATION PACKET INSTRUCTIONS Dear Parent/Guardian, The following forms must be completed and provided at the time of registration at your child’s assigned school: 1. Parental Screening Questionnaire: To be completed by Parent/Guardian 2. Immunization Record: To be completed by Physician 3. Physical Examination Form: To be completed by Physician Please be sure to have one completed medical packet for each child you are registering. If you have any questions regarding the medical packet, please contact the nurse at your assigned school. Thank you. __________________________________________________________________________ Estimado Padre/Representante, Los siguientes formularios deben ser completados y entregados en el momento de la registración de su hijo(a) en la escuela asignada: 1. Parental Screening Questionnaire- Cuestionario de información de los padres: Esto debe ser completado por el padre/representante del niño(a) 2. Immunization Record- registro de vacunas: Esto debe ser completado por un doctor/médico. 3. Physical Examination Form- Formulario de Examen Físico: Esto debe ser completado por un doctor/médico. Por favor, asegúrese de completar un paquete médico por cada niño que está registrando. Si tiene alguna pregunta relacionada al paquete médico, por favor comuníquese con la enfermera de la escuela que le fue asignada. Gracias. __________________________________________________________________________ Estimados Pais/Encarregados de Educaçāo, Os seguintes formulários devem ser preenchidos e entregues no dia da matrícula do seu filho na escola que lhe foi atribuida: 1. Parental Screening Questionnaire- Questionário de Informaçāo dos Pais: Este deve ser preenchido pelos pais/encarregados de educaçāo do aluno. 2. Immunization Record- Registro das Vacinas: Este deve ser preenchido por um médico. 3. Physical Examination Form- Formulário do Exame Físico: Este deve ser preenchido por um médico. Por favor, certifique-se que tem o pacote completo para cada aluno que está a matricular. Se tiver algumas perguntas sobre o pacote médico, por favor entre em contato com a enfermeira da escola que lhe foi atribuida. Obrigada.
KEARNY PUBLIC SCHOOLS MEDICAL DEPARTMENT Parental Screening Questionnaire Student Name: _______________________________ Date of Birth: ___________________ PREGNANCY FULL TERM PREMATURE DELIVERY METHOD BIRTH WEIGHT COMPLICATIONS
ANY CONCERNS _____________ SPECIFY: ____________________ ____________________________ GASTROINTESTINAL ISSUES MEDICAL HISTORY CURRENT MEDICATION ____________________________
KEARNY PUBLIC SCHOOLS MEDICAL DEPARTMENT Immunization Record Dear Parent/Guardian, Please make sure your child’s required immunizations are up to date. If your child’s records are in a language other than English, please have your doctor translate those records utilizing this form. Child’s Name
Birth Date
DPT/DT: Pre K-12 4 doses (4th dose on or after 4th birthday)
1st
2nd
3rd
4th
5th
Tdap: entering grade 6 born on or after 1/1/97 IVP: Pre K-12
3 doses (3rd dose on or after 4th birthday)
1st
2nd
MMR: K-12
Measles: 2 doses (1st dose on or after 1st birthday)
3rd
4th
Mumps/Rubella (1 dose) Measles only 1st
2nd
Hepatitis B: K-12
3 doses (*4 if needed) / 2 adult doses (*last dose must be 6 months after 1st dose)
1st
2nd
3rd
*4th (if needed)
Varicella: Born on or after 1/1/98 1 dose HIB: Pre K only
1 dose On or After 1st Birthday
_____________________
Pneumococcal Conj.: Pre K only 1 dose On or After 1st Birthday
_________________
Meningococcal: entering grade 6 born on or after 1/1/97 PPD:
Date
Result:
MD Signature
Stamp Revised 01/10/16
KEARNY PUBLIC SCHOOLS ENTRANCE PHYSICAL EXAMINATION FORM
Student’s Name ____________________________________________ Age ______________ Height ________________ Weight ________________ Blood Pressure __________________ Vision: Right __________ Left __________ Glasses (Yes/No) To be worn for _____________ Scoliosis Exam _________________________ Nervous System (reflexes) _________________ Heart ___________________ Lungs____________________ Abdomen _________________ Ears ____________________ Throat ____________________ Nasal Passages ______________ Skin ____________________ Allergies: (Yes/NO) Type ___________ Asthma ____________ Medication ___________________________________________________________________ Genitals _________________ Hernia _________________ Skeletal System ________________ History of Positive TB Reaction ____________________ INH ____________ CXR ___________ Mantoux: Date planted __________ Results __________________ (May be read in school) Is there any condition or history that we should be aware of? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Any limitations for Physical Education? _____________________________________________________________________________ _____________________________________________________________________________
Tdap: entering grade 6 born on or after 1/1/97. IVP: Pre K-12. 3 doses (3rd dose on or after 4th birthday). 1st. 2nd. 3rd. 4th. MMR: K-12. Measles: 2 doses (1st ...
Central American. ❑ South American. ❑ Latin American. ❑ Other Hispanic / Latino. Question 2. What race do you consider your child? (Check all that apply).
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I, the undersigned, do hereby authorize officials of Dover Public Schools to contact directly the persons named in this document, and do authorize the named physicians to render such treatment as may be necessary in an emergency, for the health of sa
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He sido informado de que Vanderbilt University Medical Center me enviara el cobro por los servicios de hoy y no esta bajo ninguna obligacion de aceptar la ...
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I, the undersigned, do hereby authorize officials of Hennessey Public Schools to contact directly the persons named in this document, and do authorize the ...
cirugía de cataratas, cirugía reconstructiva, tomografías por emisión de positrones. (Positron Emission Tomography, PET), artroscopía, cirugía de mano, cirugía ...
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