th
1021 West 14 Street
P. O. Box 968
Hastings, Nebraska 68902-0968
Appointments (402) 463-2423
Business (402) 462-8456
Fax (402) 463-9698
Physical Exam Checklist
This information is being sent to you for an upcoming school related exam. Please review the
following section that applies to the person having the physical. If you have any questions about
this information, please call us at (402) 463-2423.
7th Grade Physical
Forms Please complete the top section of the Department of Health & Human Services “Physical
Examination Report” prior to your examination. It is required that this form be completed and
signed by Parent (or Guardian) and the child before the child is seen by the Provider.
Additionally, complete the first page of the “Preparticipation Physical Evaluation” form.
Immunizations Please bring a complete record of immunizations with you, even if child has
received all of their vaccines in the clinic.
Urine specimens are needed for all physicals. For some children this can be overwhelming, and it
is acceptable to bring a specimen from home for children of all ages. Be sure to put the child’s
name on the container. If it will be more than an hour before the appointment please refrigerate
the urine to prevent chemical changes that could affect the results. When you check in at the desk
you will be asked to deliver the specimen to the lab.
REQUIRED VACCINES:
Tdap is a tetanus diphtheria vaccine with Pertussis (whooping cough) that is now the
recommended booster for teens and adults. Current recommendations state that anyone 11-64
years of age should receive one dose.
Chicken Pox vaccine (Varivax) is now mandatory for individuals 18 years and younger to receive
two doses of the vaccine unless they have documented proof of having had chicken pox.
RECOMMENDED VACCINES:
Meningococcal (Menactra) vaccine is given to prevent specific types of meningitis prevalent in
dormitory or communal settings. This formula is designed to work for up to 10 years and is
recommended for 11-12 year olds.
HPV (Gardasil) human Papillomavirus vaccine prevents four types of HPV which have a high
incidence of causing cervical cancer and genital warts. It has been found to be most effective
when given to young girls before they are sexually active and is licensed for ages 9-26 years. This
is a three shot series given at 0, 2, and 6 months.
Hepatitis B vaccine is a three dose series that is now given with baby shots. Most children will
have had the series completed by this age. If they are not complete the series will be done at this
time. The dosing schedule is 0, 1, and 6 months. If the child has received partial series it is not
restarted.
For inquiry of Vaccine and Administration fees please call our office.
If you have questions regarding your child’s vaccine needs please ask your physician.
Rev 02/15
1021 West 14th Street
Hastings, NE
68901
402-463-2423
1021 West 14th Street
Hastings, NE
68901
402-463-2423
DENTAL EXAMINATION
Is oral hygiene adequate? _______
Number of fillings present: __________
Number of restorations needed: ________
Date(s) restorations to be completed: _____
Recommendations: ________________________________________________________
Signature _________________________DDS
Date: _________________________
SCHOOL VISION EVALUATION
This form may be utilized by a Vision Specialist
A School Vision Evaluation is required within six months prior to entering Nebraska Schools for the first
time (Kindergarten or student transferring from Out of State).
Name: __________________________________
Date:___________________
Student Status (check one): ______Beginner Grade ______Transfer from Out of State
Required Tests*
Pass
Fail
Amblyopia


Strabismus
 

Internal Eye Health
 

External Eye Health
 

Visual Acuity
Right eye @ distance (20 ft.): 20/_____
Left eye @ distance (20 ft.): 20/_____
Right eye @ near (16 in.):
20/_____
Left eye @ near (16in.):
20/_____
aided/unaided
aided/unaided
aided/unaided
aided/unaided
*A vision evaluation consisting of these required tests meets the legal requirements for the State
of Nebraska but is not a complete eye examination such as most eye doctors perform
COMMENTS/RECOMMEDNATIONS:
________________________________________________________________________
________________________________________________________________________
Evaluation performed by ___________________________________________________
(Signature)
Office Phone Number: _________________________________ Date: ______________
03/10