River Vale Schools - Standard Health Form
PLEASE PRINT	DATE _________________
Child’s Name _____________________________________________ Address _________________________________________________	GRADE _______________ Birth Date ______________
Parent or Guardian ________________________________________	Phone ____________________

IMMUNIZATION: (Mo/ Day/ Yr)
DPT. 1. _____ 2. _____ 3. _____ BOOSTER DPT _____ _____ (4 Yrs) POLIO TRIVALENT 1. _____ 2. _____ 3. _____ BOOSTER _____ _____ (4 Yrs) MEASLES (Live) after 15 months _____________	RUBELLA ___ MMR #1 _____ MUMPS______MMR #2 ___________ MANTOUX Date administered: ______________ Date Read: _______ Result _______ HIB ____________ Hep. B. 1. _____ 2._____ 3._____ VARIVAX _______

HISTORY	ALLERGY
Measles _______________ Mumps _______________ Chicken Pox _______________ German Measles _______________ Scarlet Fever _______________ Whooping Cough _______________ Rheumatic Fever _______________ Strep Infections _______________ Other _______________	Bee Venom ________________ Other ________________ Operations ________________ Serious Injury ________________

RECORD OF EXAMINATION
Date Examined _____________________ General Condition ___________________ Height _________ Eyes _________ Ears _________ Throat _________ Lungs _________ Heart _________ B.P. _________	Weight __________ Vision R/20 _____ L/20 _____ Hearing R ______ L _______ Hernia _____ Skin _____ SPEECH _________________________ ORTHOPEDIC __________________________ NERVOUS SYSTEM ____________________ SCOLIOSIS ____________________________ OTHER _________________________
LABORATORY: Urinalysis: ____________ Hct/Hgb: ______________ Other ____________

This child is in ________________ condition and may safely engage in all usual activities except those noted above.

__________________________________ _____________________________________________

PLEASE PRINT DOCTOR’S NAME DOCTOR’S SIGNATURE

__________________________________ _____________________________________________

PHONE NUMBER ADDRESS