1021 West 14 th 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. 7 th 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
DENTAL EXAMINATION Is oral hygiene adequate? Number of restorations needed: Number of fillings present: 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/ aided/unaided Left eye @ distance (20 ft.): 20/ aided/unaided Right eye @ near (16 in.): 20/ aided/unaided Left eye @ near (16in.): 20/ 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