PRESCHOOL PHYSICIAN’S FORM 2008-2009

QUEEN OF PEACE SCHOOL

2550 MILLVILLE AVE., HAMILTON, OH. 45013 863-8705

D.O.B. Ht Wt B.P.

Last Name First Middle

General appearance, nutritional state, vitality

Skin (color, condition, eruptions?)

Head (size, shape, symmetry?)

Ears (right) (left) Hearing (right) (left)

Eyes (right) (left) Vision (right) (left)

Nose

Throat

Neck (lymph nodes and thyroid)

Chest

Heart

Lungs

Abdomen (hernia?)

Genitalia

Posture & extremities (including skeletal abnormalities)

Neurological

Comments on Emotional Behavior

Speech Difficulty

Other, including lab reports

Is this child capable of carrying a full program of school work including gymnastics and athletics

YES NO Recommended restrictions

MEDICAL CERTIFICATION OR IMMUNIZATION

Butler County Health Department requires doctor’s confirmation of occurrence of communicable disease.

DISEASE 1^st Date 2^nd Date 3^rd Date 4^th Date 5^th Date

DTaP, DPT or DT

DT/Td

Polio

MMR (Measles-Mumps-Rubella)

Hepatitis B Vaccine

Varicella (Chicken pox)

Hib

Date Physician’s Signature

Physician’s Name (Printed)

Address

Telephone

PRESCHOOL

Preschool students are required to have:

· 4 doses of DPT or DTaP.

· 3 doses of Polio vaccine.

· 1 dose of MMR (Measles, Mumps and Rubella) vaccine. Vaccine must be administered on or after the 1^st birthday.

· 3 doses of Hepatitis B vaccine.

· 3 or 4 doses of HIB. Number of doses will vary with the type of vaccine used.