Dublin City School District
Students
5112 F2
Revised 6/9/15
Page 1 of 2
Preschool Health Assessment and
Annual Medical Examination
Child’s name: ______________________________________________________________________________
Birthdate: ______________________________
Age: _____________
Male:
o
Female:
o
Date of medical examination: ______________________________
Height: ____________________
Weight: ____________________
SCREENING TESTS
VISION
Date: _____________________
Distance Acuity
Right _____
Left _____
Muscle Balance
Farsightedness
Color
Wears Glasses?
Tested w/Glasses?
Referral Made?
£
£
£
£
£
£
Pass
Pass
Pass
Yes
Yes
Yes
DENTAL
Assessment
Referral Made
£ Done
£ Yes
£
£
£
£
£
£
SPEECH/LANGUAGE
Assessment
£ Done
Child has problem with:
Speech evaluation recommended?
Fail
Fail
Fail
No
No
No
HEARING
Date: _____________________
Pure Tone Testing:
Right Ear
£ Pass
£ Fail
£ N/A
Left Ear
£ Pass
£ Fail
£ N/A
Other Tests (specify) _____________________
______________________________________
Wears Hearing Aid?
£ Yes
£ No
Tested w/Hearing Aid?
£ Yes
£ No
Referral Made?
£ Yes
£ No
£ N/A
£ N/A
£ N/A
£ Not done
£ No
£ no obvious dental problems
£ Not Done
£ Articulation
£ Yes
£ no obvious speech problems
£ Rhythm
£ Voice
£ No
REQUIRED ONE-TIME LABORATORY TESTS
£ Hematocrit/Hemoglobin
£ Lead screening
Date: ______________
Date: ______________
PHYSICAL EXAMINATION
Findings:
£ Essentially normal
B.P.: ____________________
£ Language
Result: _____________________________________
Result: _____________________________________
£ Abnormalities as follows: ___________________________________
Please list primary medical diagnosis including any allergies (£ NKA): ____________________________________
MEDICAL RECOMMENDATIONS
Is this child able to participate fully in the following:
A. Classroom and academic activities? £ Yes £ No
B. Gross motor activities?
£ Yes £ No
C. Outdoor activities?
£ Yes
£ No
If no, please specify limitations: ________________________________________________________________
____________________________________________________________________________________________________
Please list any other physical, developmental, or behavioral concerns that could impact a child’s school
performance, or may require a medical plan at school: ______________________________________________
____________________________________________________________________________________________________
Medications: _______________________________________________________________________________
Health Care Provider’s Signature: _______________________________________
PLEASE ATTACH A SIGNED CURRENT IMMUNIZATION RECORD.
Date: ________________
Students
5112 F2
Revised 6/9/15
Page 2 of 2
FOR THE 2015-2016 SCHOOL YEAR, OHIO LAW REQUIRES ALL STUDENTS HAVE A MINIMUM OF THE
IMMUNIZATIONS LISTED BELOW TO ATTEND SCHOOL. A RECORD OF THESE IMMUNIZATIONS MUST
BE ON FILE WITH THE SCHOOL BY THE 14TH DAY AFTER THE STUDENT BEGINS SCHOOL OR THE
STUDENT WILL BE EXCLUDED.
VACCINES
DTaP/DPT/DT/Td
Diphtheria, Tetanus, Pertussis
POLIO
MMR
Measles, Mumps, Rubella
Hib
Haemophilus Influenzae
Type b
HEP B
Hepatitis B
Varicella
Chickenpox
FALL 2015
IMMUNIZATIONS FOR CHILD CARE, HEAD START AND EARLY
CHILDHOOD ATTENDANCE
Four (4) doses of DTaP or DT or any combination
Three (3) doses of OPV or IPV or any combination of OPV or IPV.
One (1) dose of MMR administered on or after the first birthday.
Three (3) or four (4) doses depending on the vaccine type, the age when the child began
the 1st dose and the last dose must be after 12 months
or
One (1) dose if given on or after 15 months of age
Three (3) doses of Hepatitis B. The second dose must be administered at least 28 days
after the first dose. The third dose must be given at least 16 weeks after the first dose and
at least 8 weeks after the second dose. The last dose in the series (third or fourth dose)
must not be administered before age 24 weeks.
One (1) dose of Varicella administered on or after the first birthday
Students who have spent more than 30 consecutive days in a foreign country within the past 5 years must present
proof of a negative Tuberculin test or negative chest x-ray performed in the United States prior to school entry.