Transcription of Health History and Appraisal (A-45) - New Jersey
1 STaTe OF neW JeRSeYHeaLTH History anD aPPRaISaLname of Child (last, first, )naME aDDREssPaRenTOR gUaRDIanVaccIne TYPeMEaslEs, MuMps, RuBElla (MMR)HaEMOpHilus B (HiB)**HEpaTiTis BVaRiCEllapnEuMOCOCCal COnJuGaTE ** History YeaRfOOD allERGiEsnOn-fOOD/nOn-DRuGallERGiEsasTHM aCOnVulsiVE DisORDERDiaBETEsHEaRT DisEasECHROniC OTiTis MEDiaYeaRCOnGEniTal DisORDERHeaLTH ScReenIng cODe: n = normal; R = Referred; T = Under Treatment; c = See commentsYeaRauTO iMMunE DisORDERssTREp infECTiOnsMOnOnuClEOsisJuVEnilE RHEuMaTOiD aRTHRiTisauTisM spECTRuM DisORDERsHEMaTOlOGiCalDisORDERsaDD/aDHDC OnCussiOn/TBilYME DisEasEHEpaTiTisGrade/ageDateHeightWeigh tBMi**VISIOnHeaRIngRlBOTHBOTHlRBlood pressureWith correctionWithout correctionnEuROMusC.
2 DisORDERDRuG allERGiEsYeaR provisional admission attached Date Granted:_____ Medical exemption attached Religious exemption attachedMEninGOCOCCalTdapHEpaTiTis a **HpV (HuMan papillOMaViRus) ** OTHEROTHERDate of Birth (Mo/Day/Yr) sex Male femaleTElEpHOnE RegISTRY nUMBeRDate:Titer:Titer:Titer:Date:Date:4 th DoseMo/Day/YrMeaslesRubellaMumpsHepatiti s BTiter:Date:Varicella3rd DoseMo/Day/Yr2nd DoseMo/Day/Yr1st DoseMo/Day/Yr5th DoseMo/Day/YrpOliO inaCTiVaTED pOliO VaCCinE(ipV)If oral vaccine, indicate (OPV) in corner boxRlDatepureToneTestedReadMantoux Result (MM) oriGRa ResultTB screening (Mantoux or iGRa Test)DateDateMuscle BalanceColor perception Date ResultsChest X-Ray ResultDatenormalabnormalMedicationReacto r no Rx Date startedDate CompletedE92-08302a**REQuiRED fOR DaY/CHilD CaRE EnROllEEs (2 Months-5th Birthday Only)
3 **not Required a-45 sTaTE Of nEW Jersey -DEpaRTMEnT Of EDuCaTiOn/DEpaRTMEnT Of HEalTHRevised august 2016 BiEnnial sCOliOsis sCREEninG(Beginning at age 10)Referred for abnormal result DateDateDateDateDateDipHTHERia, TETanus, pERTussis (DTap) or any combination(If Td or DT, indicate in corner box)Titer:Date:LeaD ScReenIngTest Date ResultHISTORYHISTORYHISTORYD ocument below single antigen vaccine receipt,serology titers, or varicella disease historyinfluEnza(flu)OTHERPHYSIcaL eXaMInaTIOnSGrade/ageDateType of Examsignificant findingsMedical providerRECORD: findings and Recommendations of physicians including medications, operations and injuries; Modification ofschool program; Referrals and follow-up; Conference with parents, Teachers; Counseling with student.
4 Individualnurses notes must be
