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Get Cheshire Academy Immunization Form

The information supplied will be used as medical history when providing health care is strictly for the use of our health services and will not be released without the student s consent. Name Date of Birth/ / Last First MI Month/ day/ year B/P Pulse Height ft in. Weight lbs Corrected Vision Right Eye 20/ Left Eye 20/ Urinalysis Date Sugar Albumin Tuberculin Mantoux required yearly for International students Date NegativePositivemm If positive Chest x-ray date Results B.C.G. International Students Date SYSTEM Head Ears Nose or Throat Respiratory Cardiovascular Gastrointestinal Hernia Eyes other than Acuity Genitourinary Musculoskeletal Metabolic/Endocrine Neuropsychiatric Skin Teeth Menstrual normal Immunization Record Fill in all vaccines received month day and year Note minimum requirements DPT /DTaP/Td Tdap booster Polio MMR Measles Mumps Rubella Meningococcal MCV4 or A C Y W-135 after age 11 Hepatitis B Varivax Dose 1 Dose 4 Dose 5 Dose 2 Dose 3 Varicella Chicken Pox disease date COMMENTS Is the patient now under treatment for any medical or emotional condition No Is the patient allergic to any medications Yes Yes If yes please specify. If yes please list. Is there a health condition which may require emergency action at school e.g. seizures allergies Yes Is there a history of learning disability Yes Recommendations for physical activity sports Unlimited Limited Please specify if limited. Comments and Recommendations attach additional sheet if necessary MD/APRN/PA SIGNATURE Date of Physical Examination// Address Phone Fax Please return completed form by June 1 2012 ATTN Cheshire Academy Health Center 10 Main Street Cheshire CT 06410. PHYSICAL EXAMINATION-CHESHIRE ACADEMY ACCESS CHESHIRE 2012 TO THE EXAMINING HEALTHCARE PROVIDER The State of Connecticut requires all students to present evidence of immunization against polio diphtheria tetanus pertussis measles mumps rubella varicella hepatitis B and meningitis in order to register for classes. The information supplied will be used as medical history when providing health care is strictly for the use of our health services and will not be released without the student s consent. Name Date of Birth/ / Last First MI Month/ day/ year B/P Pulse Height ft in* Weight lbs Corrected Vision Right Eye 20/ Left Eye 20/ Urinalysis Date Sugar Albumin Tuberculin Mantoux required yearly for International students Date NegativePositivemm If positive Chest x-ray date Results B*C*G* International Students Date SYSTEM Head Ears Nose or Throat Respiratory Cardiovascular Gastrointestinal Hernia Eyes other than Acuity Genitourinary Musculoskeletal Metabolic/Endocrine Neuropsychiatric Skin Teeth Menstrual normal Immunization Record Fill in all vaccines received month day and year Note minimum requirements DPT /DTaP/Td Tdap booster Polio MMR Measles Mumps Rubella Meningococcal MCV4 or A C Y W-135 after age 11 Hepatitis B Varivax Dose 1 Dose 4 Dose 5 Dose 2 Dose 3 Varicella Chicken Pox disease date COMMENTS Is the patient now under treatment for any medical or emotional condition No Is the patient allergic to any medications Yes Yes If yes please specify.

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