To be completed by licensed healthcare provider:
Physician (MD or DO), Clinical Nurse Specialist (APN), Advanced Practice Nurse (APN), or Physician's Assistant (PA)
To Parent or Guardian:
In order to provide the best educational experience, school personnel must understand your child's health needs. This form requests information from you (Part I) and your health care provider (Parts I, II, and III). All students in Michigan public schools must provide documentation of current immunizations, and a current (within 2 years) physical examination upon school entry and at ninth (9 th ) grade.
1
 School (readiness or adaptation, after school, parent-teacher communication, maturity, performance, special services)
 Mental and Physical Activity (healthy weight, well-balanced diet, physical activity, limited screen time)

Emotional Well-Being (family time, social interactions, self-esteem, resolving conflicts, friends)

Physical Growth & Development (dental care, healthy eating, puberty)
 Injury & Illness Prevention & Safety (seat belt or booster seat, bicycle safety, swimming, abuse protection, guns, fire safety, supervision, sunscreen, internet, infection, disaster planning)
 Immunizations

Influenza (seasonal) vaccine is recommended each year for all children (6 months and up).

Human
vaccine (HPV) is recommended for all girls and boys (ages 11 or
12, minimum age 9) to prevent cancers, pre-cancers, and genital warts.

Hepatitis A, Meningococcal, and Pneumococcal vaccines are recommended for certain high risk groups.
KINDERGARTEN 2 : DTaP/DTP: 4 or more doses. If the 4 th dose was prior to the 4 th birthday, a 5 th dose is required.
Polio: 3 or more doses. If the 3r d dose was prior to the 4 th birthday, a 4 th is required.
MMR 3 : 2 doses. The 1st dose should be given on or after the 1s t birthday. The
2 nd
dose should be given after the
4 th
birthday.
Hep B 3 : 3 doses.
Varicella 4 : 2 doses. The l' dose should be given on or after the 1s t birthday and the 2n d dose after the 4t h birthday.
GRADES 1-6: DTaP/DTP: 4 or more doses. If the 4 th dose was prior to the 4 th birthday, a 5 th dose is required.
Students who start the series at age 7 or older only need a total of 3 doses. A booster dose of Td or Tdap is recommended by the Division of Public Health for all students at age 11 or five years after the last DTap, DTP, or DT dose was administered - whichever is later.
Polio: 3 or more doses. If the 3r d dose was prior to the
4 th birthday, a 4 th is required.
MMR 3 : 2 doses. The 1st dose should be given on or after the P t birthday. The r d dose should be given after the 4 th birthday.
Hep B 3 : 3 doses. For children 11 to 15 years old, two doses of a vaccine approved by CDC may be used.
Varicella 4 : 2 doses. The l s t dose must be given on or after the 1st birthday and the 2n d dose after the
4 th
birthday.
Based on Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, (3' ed.) AAP, 2008
Children who enter school prior to age four shall follow current Michigan of Public Health recommendations. Disease histories for measles, rubella, mumps and Hepatitis B will not be accepted unless serologically confirmed.
Pre-K, Kindergarten, 1.
,,
-6th Grade

4 Varicella disease history must be verified by a health care provider to be exempted from vaccination_
CHILD'S NAME _____________________________________________
PART I — HEALTH HISTORY
To be completed by parent/guardian prior to exam
The healthcare provider should review and provide comments in the last column.
Name:
Date:
Gender:
Examiner:
DOB:
Developmental delay (speech, ambulation, other)?
Serious injury or illness?
Medication?
Hospitalizations?
When?
Surgery? (List all)
When?
What for?
What for?
Ear/Hearing problems?
PARENT
Yes No
HEALTHCARE PROVIDER COMMENT
Heart problems/Shortness of breath?
Heart murmur/High blood pressure?
Dizziness or chest pain with exercise?
Allergies (food, insect, other)?
Family history of sudden death before age 50?
Child wakes during the night coughing?
Diagnosis of asthma?
Blood disorders (hemophilia, sickle cell, other) ?
Excessive weight gain or loss?
Diabetes?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Loss of function of one or paired organs (eye, ear, kidney, testicle)?
Seizures?
Head injuries/Concussion/Passed out?
Muscle, Bone, or Joint problem/Injury/Scoliosis?
ADHD/ADD?
Behavior concerns?
Eye/Vision concerns?

Glasses
❑
Contacts

Other
Dental concerns?

Braces
❑
Bridge
❑
Plate
❑
Other?
Date of exam _______________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Other diagnoses?
Does your child have health insurance?
Yes No
Yes No
Does your child have dental insurance Yes No
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Signature
MI Physical form Page 1
Date
Pre-K, Kindergarten,- 4th Grade
-
-

CHILD'S NAME ___
PART II — IMMUNIZATIONS
Entire section below to be completed by MD/DO/APN/NP/PA
Printed VAR form may be attached in lieu of completion.
Im munizations
—
Shaded Vaccines Required. Regulations is located at Title 14 Section 804 Immunizations
DTaP/ DT
/ /
OPV/ IPV
/ /
PCV7/ PCV13
/ /
DTaP/ DT
/
OPV/ IPV
/
PCV7/ PCV13
/
/
/
/
DTaP/ DT
/ /
OPV/ IPV
/ /
PCV7/ PCV13
/ /
/
DTaP/ DT
/
OPV/ IPV
PCV7/ PCV13
/
/ /
/
DTaP/ DT
/ /
OPV/ IPV
/ /
PCV7/ PCV13
/ /
Hib
/
MMR
/
VAR
/
MCV4
/
/
Hep A
Influenza
/
Other:
/ /
/
/
/
/
/
/
Hib
/
MMR
/
VAR
/
MCV4
/
/
Hep A
Influenza
/
Other:
/ /
/
/
/
/
/
/
Hib
I I
HepB fllepB-2
/ /
RV-2/ RV-3
/ /
HPV
/
Td/ Tdap
/
PPSV23
/
Other:
/ /
/
/
/
I
Hib
/
HepB /HepB-2
/
RV-2/ RV-3
/ /
HPV
/
/
Td/ Tdap
/
/
/
PPSV23
/
Other:
/
I
I
HepB
RV-3
/
HPV
Td
Other:
/ /
/ /
/ /
/ /
/
Entire section below to be completed by MD/DO/APN/NP/PA
Height:
(inches)
Weight:
(pounds)
BMI: BMI Percentile: BP: Pulse: Other:

Problem Identified: Referred for treatment
 No Problem: Referred for prevention
 No Referral: Already receiving dental care
All new enterers must have TB test or TB Risk Assessment, which must be done within 12 months prior to school entry.
Risk Assessment: Date Results:
❑
At Risk
❑
No Risk
Mantoux Skin Test: Date Results: MM
Other: (type) Date Results: MM
Blood lead test required for children age 6 months through 6 years
Date:
Hearing: Type:
Results:
Date: Results:
Vision: Type:
Other: Type:
Date:
Date:
Results:
Results:
Referral:
❑
No
Referral:
❑
No
Referral:
❑
No
❑
Yes
Date
❑
Yes
Date
E Yes
Date
MI Physical form Page 2 Pre-K, Kindergarten- 4thGrade

PHYSICAL
EXAMINATION
General Appearance
Skin
Eyes
Ears
Nose/Throat
Mouth/Dental
Cardiovascular
Respiratory
Thyroid
Gastrointestinal
Genito-Urinary
Neurological
Musculoskeletal
Spinal examination
Nutritional status
Mental health status
CHILD'S NAME ________________________________
PART IV — COMPREHENSIVE EXAM
Entire section below to be completed by MD/DO/APN/PA
NORMAL
Check ( I)
ABNORMAL REFERRAL
HEALTHCARE PROVIDER
COMMENT
FOR CHRONIC & LIFE THREATENING CONDITIONS:
Children with life-threatening conditions need an emergency care plan for school.
Please attach care plan, protocols, and/or emergency care plan.
Please provide the parent with information on Special Needs Alert Program (SNAP) for EMS.
Recommendations or Referrals:
DIAGNOSIS
EMERGENCY PLAN
ATTACHED
YES NO
CARE PLAN OR
PRESCRIPTION
PLAN ATTACHED
YES NO
Print Name: ______________________________ Signature: ____________________________ Date: _____
OPhysirian (MD or DO) DClinical Nurse Specialist (APN) DAdvanced Practice Nurse (APN) uPhysician Assistant (PA)
Address: Phone:
MI Physical form Page 3 Pre-K, Kindergarten- 4th Grade

2014-2015
Student Name: ________________________________________________ DOB: ________________
Allergies: __________________________________________________________________________
Current Medications: ________________________________________________________________
The following medications / treatments are available in the nurse's office. Please check to indicate which may be administered to your child on an as-needed basis:
Cough drops
Tylenol
Motrin or Advil
Benadryl
Tunis or Maalox
Children's Mucinex Cough
Anbesol or Orajel
Neosporin
Benadryl topical lotion or spray
Hydrocortisone Cream
Sterile eye wash
Sunscreen (parent must provide)
Insect repellant (parent must provide)
By signing below, you acknowledge and agree to the following:
1. The parent or guardian MUST make school nurse aware of any allergies (especially to medication) or medical conditions your child has, and also of any medication your child takes on a regular basis.
2. Restraint must be used by the school nurse in dispensing non-prescription medications. The child's complaint and symptoms must be assessed to determine if other measures can be used before medication is given.
3. All medications sent to school must be in the original container, and must be kept in the nurse's office. The only exception is for certain emergency medications. If your child has an emergency medication, you MUST make arrangements with the nurse.
4. Dosage and frequency for all medications is determined according to package directions, unless otherwise ordered by physician or other qualified healthcare provider. Medications administered by school nurse may be name-brand or generic equivalent.
I have read and agree to the above section and give my authorization for the school nurse to
administer the medications I have checked above:
Parent/Guardian signature
Print Parent/Guardian name
Date
Phone number (daytime)
DECLINING NON PRESCRIPTION MEDICATIONS
I have read the above section and do not give my authorization for the school nurse to administer non-prescription medications to my child. I understand I may revoke this refusal in writing at any time by completing the above section.
Parent/Guardian signature Date
Print Parent/Guardian name Phone number (daytime)

2015-2016
Request to Have Prescription Medication/Treatment Administered in School
If it is necessary for your child to receive medication during the school day, please do the following:
1.
Send the medication to school with a responsible ADULT
2.
Send the medication in the original container with the PRESCRIPTION LABEL affixed, containing student name, medication name, time dose and date prescribed.
3.
Count tablets (unless the number of tablets is the exact number on the label) or approximate amount of liquid in the bottle.
4.
Fill out the following information:
Date _______________
Student's Name ______________________________________________________
Medication ________________________________________________________
Dose _____________________ Time ___________________________________
Reason for Medication __________________________________________________
ALLERGIES TO ANY MEDICATIONS ________________________________________
Number of tablets sent _____________
Amount of liquid _________________
I am aware that the school nurse may only give medications as prescribed by a healthcare provider. I am also aware that the school nurse may need to contact the prescribing healthcare provider or pharmacist regarding the medication/treatment, and I give my permission for him or her to do this.
Parent/Guardian Signature _________________________________ Date _____________
Nurse's Signature _________________________________________ Date _____________
Number of tablets/amount of liquid received ____________________ Date _____________