RHINEBECK CENTRAL SCHOOL DISTRICT

P.O. Box 351

RHINEBECK, NY 12572

NAME ___________________________ D O B ___________________ GRADE________

HISTORY OF PAST ILLNESSES:

CHICKEN POX ____________________

EPILEPSY ________________________

PNEUMONIA _______________________

HEART DISEASE ___________________

WHOOPING COUGH _______________

ASTHMA/ALLERGIES_______________

OPERATIONS/SERIOUS INJURIES________________________________________________

IMMUNIZATION RECORD:

DTAP ____ ____ ____ ____ _____ HIB _____ _____ ______ _____ PPD ________

OPV _____ _____ ____ ____ ____ HEP B ____ ____ ______ Tdap ________

IPV ______ _____ ____ _____ ___ HPV ____ _____ _____ Td _________

DPT _____ _____ _____ _____ VARICELLA ____ ____ Other _________

MMR ______ ______ MENINGITIS __________

PHYSICAL EXAM: DATE: ___________

HEIGHT __________ WEIGHT ___________ BP _________ BMI ____________

SCOLIOSIS ________THYROID ____________TONSILS ___________

HEART ___________ LUNGS ______________ HERNIA _______________

TEETH ___________ EARS ________________TANNER LEVEL ___________

SKIN _____________ SPEECH ______________ FEET _________________

VISION: 10/10 =20/20 R _____ L _____ AUDIOGRAM : NORMAL ____ ABNORMAL _____

GENERAL CONDITION /COMMENTS: ______________________________

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(SIGNATURE OF PHYSICIAN) OFFICE STAMP