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HEALTH FORM
LEXINGTON
PEDIATRICS, P.C.
PEDIATRIC & ADOLESCENT
MEDICINE
19 MUZZEY STREET
LEXINGTON, MASSACHUSETTS
02421
Name:
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Sample Page
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D.O.B.
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00/00/2000
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Date of exam:
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________
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Height:
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_____
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Weight:
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_____
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BP:
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_____
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BMI:
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_____
| Immunizations
| Hep_B |
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| DTAP |
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| Td |
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| Tdap |
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| IPV |
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| PCV_7 |
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| HIB |
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| MMR |
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| Varicella |
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| Influenza |
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| Menactra-Menomune |
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| Hep_A |
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| Typhoid |
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| Gardasil-HPV |
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Immunizations are up to date: YES
NO
Recent tests/screenings
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TB exposure
risk: |
LOW HIGH |
Audio : P
F |
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PPD:
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Vision : P
F |
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Lead exposure risk:
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LOW HIGH |
Stereopsis : P
F |
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Lead screen:
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Hct
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Cholesterol
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Urinalysis
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Patient X has been examined
on this date and found to be free of any acute or chronic
disease.
He/she may attend school/camp and engage in all
activities including sports, except as noted below.
_______________________________________________________________
THIS FORM IS VALID FOR ONE YEAR FROM THE
DATE OF THE EXAM.
Additional Information
:
Medicine Allergies
:
Food
Allergies :
Current
Medications:___________________________________________________________ |
SIGNATURE
_____XXXXXXXXXXXXXXXXXXXX________
MD/PNP: DATE: ______________
| Daniel
I. Palant, M.D. |
|
Victoria
J. Arthur, M.D. |
|
Jane
L. Berman, R.N. P.N.P |
| Wendy
L. Wornham, M.D. |
|
Karen
D. Sullivan, M.D. |
|
Margerie
G. Dembrowski, R.N. P.N.P |
| Julie
B. Dollinger, M.D. |
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Betty
Borghesani, R.N. P.N.P |
|
Kathleen
M. Manchester, R.N. P.N.P |
Prepared by:
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