1. education
2. school

Instructions
Please do not separate the pages of this packet.
Please read and complete the entire packet.
Please have the required parties sign in the appropriate
areas.
All of the packet should be completed before arriving on
campus for registration.
MEDICAL INFORMATION CHECKLIST
Dear Carson Long Parents:
Your application has been received and accepted for the
Congratulations!
School Year 2013-2014. Please complete all forms and return them to the
school no later than August 1, 2014. Below you will find a complete checklist
to help you. Some of the documents in this packet are for information only, so
please do not return them to the infirmary staff. PLEASE NOTE ALL FORMS
MUST BE IN ENGLISH-PLEASE USE BLUE OR BLACK INK ONLY. Please fill
out all forms in entirety! If forms are received incomplete, it will have to be
done at registration which will cause YOU time delays and going to the end of
the line.
• Cadet Health record (4 page folded form)
• Checklist Details and Definitions
• Medical Letter to Parents-Must be signed by Parent/Guardian
• Privacy Act Statement (to be signed by parents)
• Pennsylvania Department of Health-Certificate of Immunization (new
cadets only)
• Substance Abuse Form (Signatures required by Parent and Cadet)
• Consent for Flu Vaccination (All Cadets)
• Student Illness/Accident Insurance Plan (Moore Insurance Agency)
• Authorization for Dispensing Medication
• Medication Policy
• Medical Agreement and Release to Treat
• Bloomfield Pharmacy
• Emergency Medical Information
• PIAA Pre-participation Physical
CHECKLIST DETAILS AND DEFINITIONS
•
MEDICAL AGREEMENT AND RELEASE TO TREAT- One Page form must be
signed each year prior to admission.
•
EMERGENCY MEDICAL INFORMATION- The form must be filled out
completely each year. DO NOT WRITE “same as last year”.
•
PERMISSION TO ADMINISTER MEDICATION- One page form just must be
filled out even if your son is not currently taking medications. He may need to
do so later, if he becomes injured or ill.
•
PHARMACY APPLICATION- One page credit application for Bloomfield
Pharmacy our contract pharmacy. You will be required to provide a credit card
number to guarantee payment.
•
COMMONWEALTH OF PENNSYLVANIA SCHOOL ENTRANCE HEALTH
FORM: Four page WHITE FORM required by Carson Long Military Academy
every year on or after June 1st. This form must be signed by a physician and
must include all current and required immunizations. DO NOT WRITE SAME
AS LAST YEAR OR SEE ATTACHED.
•
CLMA ATHLETIC PARTICIPATION FORM- Multi-page WHITE FORM required
by the Pennsylvania Interscholastic Athletic Association (PIAA) every year for
your son to participate in any sport or school-related activity. This form must
be signed by the physician. Parent and student signatures required.
•
INSURANCE CARD- Please contact your insurance company for coverage
verification of your son while away from home!! Please photocopy the front
and back of your current medical, dental, and prescription cards, and give extra
cards to the infirmary for use when needed. Out of state Medicaid plans are not
accepted in PA so you must purchase school insurance.
•
CREDIT CARD- Please provide a copy for use when your son needs local
medical services and/or supplied not covered by insurance. The expiration
date must be valid for the entire school year.
•
The forms contained in this packet may seem redundant but not all forms are
kept in the same place. Therefore, we need all forms filled out completely and
signed where required.
MEDICAL LETTER TO PARENTS
Dear Carson Long Parents:
We know that you want to do as much as you can to have your son start a new academic year
as easily as possible. The following recommendations and requirements will help ensure a
smooth transition into the CLMA for the 2013-2014 school year.
1. Complete all medical forms in the registration packet COMPLETELY before
the first day of school. Incomplete forms will slow you down at check-in and
may delay your son’s ability to participate in campus activities.
2. A complete physical and labs must be performed prior to school. Physical
form and lab test results must be completed prior to the first day of school
and provided to the nurse. We recommend that you schedule physicals for
AFTER June 1 of each year, to ensure that the physical is current through the
entire school year.
3. Complete and current immunization records MUST be submitted by the
first day of school by state law.
Immunizations, lab results and physical are most critical, per Commonwealth of Pennsylvania
law. If these are not provided by the date of enrollment, we are required to have your son
return home and have your son placed on in-school suspension until completion of the
records. These services will be charged to the parents/guardians at registration if we must get
them completed here.
4. Make sure that your son has current health insurance coverage, that it
covers him while away at school and that all necessary information is
provided to CLMA on the day of enrollment. (A photocopy of your medical
insurance card, front and back, is required. We must have the contract
number and address of your insurance company- it should be attached to
the Cadet Health Record Form.) Health insurance must be valid for the State
of Pennsylvania, or you must purchase coverage through the school-offered
insurance program. If your insurance is Medicaid other than PA Medicaid, you
must purchase school insurance. Please see enclosed insurance information
and form for your insurance provider. If there is a change in your son’s
insurance at any time during the school year, the nurse must be notified with
the updated changes immediately. If the nurse is not promptly notified, the
parent/guardian will be responsible for any expenses incurred by your son.
We strongly encourage you to check the cost and amount of coverage provided
by your current insurance. You may find that it will be less costly to purchase
our school insurance than to incur high deductible and co-pay costs. Please
check for extra riders available thru your insurance.
5. Please be prepared to provide credit card information to cover medical
expenses not covered by your insurance provider. You will be contacted by
the provider of services for this information.
Please note the following infirmary and medical requirements for 20132014.
1. All medications must be kept in the infirmary (including
vitamins). Parents accompanied by the student should bring
medications to the registration desk on arrival at school.
Absolutely no medications (prescribed or non-prescribed) are
permitted in the students rooms without the authorization of
the school nursing/medical staff. There will be no
prescription medication sent home with your son over the
holidays or breaks. Please make sure you have an adequate
supply at home. Send all medications directly to CLMA
Attention Nurse. Do not give your son medications to bring to
school.
2. Any non-prescription medication given through the infirmary
will be ordered from the Pharmacy for your son.
3. If the school doctor refers your son to any medical specialists
*other than emergency situations) you will be notified first for
permission to have your son seen by the specialist, and also for
YOU to check with your insurance for proper coverage or to set
up payment arrangements at the specialist.
4. The State of Pennsylvania now requires a meningococcal
vaccine.
PLEASE SIGN AND DATE THIS AT THE BOTTOM. DETATCH AND RETURN
THIS PAGE WITH THE CADET HEALTH RECORD.
Please direct your questions to the infirmary nursing staff at (717)-582-2518.
We look forward to marking your son’s Carson Long experience a healthy one.
Sincerely,
Mrs. Teresa Kuhn, R.N.
School Nurse
I have read, understood, and will comply with the above statements.
___________________________________________________
Parent/Guardian Signature
________________________
Date
NOTICE OF PRIVACY PRACTICES
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
CADET: ____________________________________DOB:_____________________
Each time your child visits our infirmary, a hospital, physician or other health care provider, a
record of their visit is made. Typically, this record contains your child’s symptoms,
examination and test results, diagnosis, treatment and a plan for the future care. This
information is referred to as the medical record and it serves as (1) a basis for planning his
care, (2) a means of communication among the health and school professionals; (3) a legal
document describing the care he received; (4) a means by which you and a third-party payer
can verify that services were rendered; (5) a source of information for public health officials,
and, (6) a tool for improving the care we deliver.
YOUR HEALTH INFORMATION RIGHTS
Although your child’s health record is the physical property of the medical department of this
facility, the information belongs to you. You have the right to (1) request a restriction on
certain uses and disclosures, (2) inspect or obtain a paper copy of the information upon
request (there will be a copying fee); (3) obtain an accounting of disclosures; (4) request
communication of information by alternative means; and (5) revoke your authorization to
use/disclose your child’s health information-except to the extent that action has already been
taken.
OUR RESPONSIBILTIES
CLMA is required to (1) maintain the privacy of your child’s health information: (2) provide you
with a notice as to our legal duties and privacy practices; (3) abide by the terms of this notice,
and (4) accommodate reasonable requests to communication health information by alternative
means or at alternative locations. We reserve the right to change our practices and make the
new provisions effective for all protected health information we maintain. We will not use or
disclose your child’s health information without your authorization, except as described above.
FOR MORE INFORMATION
If you have any questions, please contact CLMA infirmary at (717)-582-2518. If you believe
that your child’s privacy rights have been violated, you have the right to file a written complaint
with the Dept. Of Health and Human Services, Office of Civil Rights; 200 Independence Avenue;
Washington DC 20201; toll free (877)-696-6775 regarding violations of the provision of this
notice or the policies and procedures of our office.
I acknowledge that I have received a copy of this notice of privacy practices and consent
form my child’s name, address, phone number, social security number, insurance
information, and other pertinent health information to be given to any other health care
providers caring for my child which may include: pharmaceutical care, dental care, and
physical or occupational therapy services.
_____________________________________________
Parent/Guardian Signature
_____________________
Date
SUBSTANCE ABUSE PROGRAM CONFIDENTALITY FORM
CADET’S FULL NAME: __________________________________________________________________
The confidentiality of alcohol and drug abuse records is protected by State and Federal laws
and regulations. Generally, under the Federal Regulations, the programs may not say to
people outside the program that a person attends the program, or disclose any information
identifying a person as an alcohol or substance abuser UNLESS:
1.
2.
3.
4.
The person consents in writing:
The disclosure is allowed by a court order;
The disclosure is made to medical personnel in a medical emergency
The disclosure is made to qualified personnel for research, audit, or program
evaluation;
5. A crime is committed by a person either at the program, or against any person who
works for the program or threatens to commit such a crime;
6. Child abuse or neglect are suspected—State Law requires staff to report child abuse or
neglect to Social Services
7. The person is in danger to self or to others, or is unable to care for self.
A violation of Federal law and regulations by a program is a crime. Suspected violations may
be reported to the United States Attorney in the district where the violation occurs.
Currently this policy applies to Carson Long Military Academy’s Tobacco Cessation Program.
I hereby acknowledge that I received this notice and that I understand the notice.
___________________________________________
____________________________________
Cadet Signature/Date
Parent/Guardian Signature/Date
______________________________________________
Witness Signature/Date
Consent for Flu Vaccination
Due to the close living proximity of the cadets, our physicians have recommended the
flu vaccination be administered to those cadets who are eligible.
Eligibility qualifications: You son cannot be allergic to eggs or egg products.
Vaccinations will probably be given early November. The cost of the vaccination will
be in the vicinity of $25-$40. In order for your son to receive the flue vaccination,
please fill in the consent form below.
Thank you,
Mrs. Kuhn, R.N.
Please Print:
I give/do not give my permission for my son ________________________________________
to receive the flu vaccination. I understand that my son is NOT allergic to eggs or egg
products.
I further understand that the fee for the flu vaccination will be billed to my main
account after the shot is given.
_________________________________________
Parent/Guardian Signature
________________________________________________
Printed/Typed Name of Parent/Guardian
________________________
Date
CARON LONG MILITARY ACADEMY
NEW BLOOMFIELD, PENNSYLVANIA
AUTHORIZATION FOR DISPENSING MEDICATIONS
Cadet’s Name: _____________________________Date:_____________
Part I: TO BE COMPLETED BY PHYSICIAN
Diagnosis______________________________________________
Name/Dosage of Medication(s)
1._________________________
2._________________________
3._________________________
4._________________________
If PRN, state frequency and indication___________________________
________________________________________________________________
________________________________________________________________
(Physician’s Name-Please print)
(Phone Number)
________________________________________________________________
(Physicians Signature)
(Date)
Part II: TO BE COMPLETED BY PARENT/GUARDIAN
I authorize Carson Long medical staff and their designee to dispense the above prescribed
medication to my son __________________________________. I do hereby release, discharge, and
hold harmless, Carson Long Military Academy, its agents, and employees, from any and all
liability whatsoever in connection with the administration of medication to my son.
Parent/Guardian Signature
Date
Parent’s/Guardian’s Name-Please Print
Phone Number
•
•
MEDICATION POLICY
Never pack medication in luggage.
All medications are to be turned in at the infirmary table at the time of registration.
•
All medications must be labeled with cadet name and correct dosage, or they will be sent home
with the parents. Do not remove pharmacy labels.
•
If there are changes to your son’s medications or scheduled dosage during the school year, a
doctor’s order must be provided.
•
The school nurse will provide, for our pharmacy, common over-the-county (OTC) medications for
minor ailments as well as first aid supplies. Both will be dispensed and documented in the
infirmary. (An order will be placed at pharmacy for OTC meds/supplies and this will be billed to
you).
•
A cadet may bring his own supply of OTC medications, but they must be labeled with the cadet’s
name and KEPT in the infirmary. No medications may be kept in the cadet’s possession—
except prescription inhalers and topical ointments—these must be shown to the nurse first.
•
No non-prescription body builders, weight loss/gain or other herbal supplements will not be
permitted on campus. They are considered contraband and will be confiscated and destroyed.
If you want your son to take a vitamin tablet that is more potent than a single daily
multivitamin with the minimum RDA requirements, please provide a doctor’s order or
properly labeled prescription bottle.
•
It is the parent/guardians responsibility to refill routine or scheduled medications. Do not
forget to mark your calendars for refills and allow at least five days for mailing. Medications
must be mailed directly to the infirmary and not sent to the cadet. Please keep enough of
the cadet’s medications on hand at home for school leaves and breaks. No medications will be
sent home at the end of the year. It is parental responsibility to pick up ALL medications on the
last day of school. Remaining medications will be discarded promptly after the last day of
school! No medications will be sent home- No Exceptions!
•
Licensed nurses will dispense medications. Cadet compliance is documented and missed
doses are subject to consequences. Therefore, cadets have an opportunity and incentive to
pick up their doses—but it is their responsibility to know their medication and dosage times and
seek treatment accordingly. Medication times are 7:45 a.m., 12:15 p.m., 3:00 p.m., 6:00 pm.,
and 8:00 pm. Monday– Friday. Weekend times vary with weekend school schedules.
•
•
•
•
OTC medications are administered after assessment by a nurse during Sick Call.
Cadets found with any medications or substances in their possession will be subject to the
consequences outlined in the Illegal Drug Policy.
Cadets assessed too ill for nursing interventions are sent to the doctor for treatment. The nurse
will make appointments, ensure follow-up and arrange transportation as needed. ALL expense
including driver and mileage fees will be billed to parents.
Bed Rest in the infirmary under nurse observation or Room Rest will be assigned per doctor’s
orders or the judgment of the nurse. Please do not call the nurse and request your son to stay
in the infirmary!
•
Restrictions from participation in sports or other school activities are based upon
doctor’s orders or the judgment of the nurse.
•
PLEASE SUPPORT OUR GOAL TO PROVIDE CARE, DECREASE CONTAGION AND
MAXIMIZE CLASS ATTENDANCE
Parent Signature:_________________________________________Date:________________________
MEDICAL AGREEMENT & RELEASE TO TREAT
CADET: __________________________________________________
Last Name
First Name
Middle
DOB____________________
The undersigned, Parent/Guardian, authorizes Carson Long Military Academy to
obtain immediate medical or dental care and consents to the hospitalization of, the
performance of necessary diagnostic tests upon, the use of surgery on, and/or the
administration of drugs to the above-named student if emergency occurs when the
Parent/Guardian cannot be located immediately. It is understood that all fees
insurance does not cover or pay for; the Parent/Guardian is responsible for. Fees
charged by collection agencies and/or attorneys if they are required for account
collection are parent responsibility.
Authorization is given to Carson Long Military Academy staff and faculty to sign the
necessary consents for such medical treatment in the event the Parent/Guardian
cannot be contacted.
The Parent/Guardian understands and agrees that Carson Long Military Academy
does not accept liability for the costs of any medical procedures the student may
require as a result of illness or accident. Payment for medical and/or dental services
provided to this student will be made by Parent/Guardian’s health insurance or as
otherwise arranged and detailed on the Emergency Information Sheet, or, failing the
same, by the Parent/Guardian individually.
The Parent/Guardian hereby gives permission to Carson Long Military Academy
staff and faculty to administer prescribed medications to the above-named student in
accordance with the directives of the prescribing physician.
The Parent/Guardian understands, agrees and consents to having the above-named
student tested, per Carson Long Military Academy’s Blood-Borne Pathogen Policy,
If he exposes his body fluids or is exposed to another student’s/employee’s body
fluids. This student will also be subject to drug screens, per Policy.
_________________________________________________
Signature of Parent/Guardian
__________________
Date
_________________________________________________
Printed Name of Parent/ Guardian
___________________
Date
BLOOMFIELD PHARMACY
TO:
PARENTS/GUARDIANS OF CLMA CADETS
SUBJECT: MEDICATIONS
So that we may provide your son with medical care, we ask that you complete
the following. The information you provide will be kept strictly confidential.
Your son’s medical history will be maintained in a computer database, and will
be reviewed and updated each time prescriptions are filled. This important
information will aid in the detection and prevention of potential harmful effects
that result from drug interactions and drug allergies. THERE IS NO
CHARGE FOR THIS NECESSARY SERVICE.
CADET: _____________________________________ _________
Last
First
Middle
DOB: _______ ________
ADDRESS:_________________________________________________________________________
STREET
CITY
ST
ZIP
HOME PHONE:_______________________________ MOBILE PHONE:__________________________
WORK PHONE:_______________________________ E-MAIL:__________________________________
DRUG ALLERGIES: (CIRCLE ALL THAT APPLY)
1. Penicillin
2. Sulfa Drugs
3. Tetracycline
4. Erythromycin
5. Keflex, Ceclor
6.
7.
8.
9.
10.
Aspirin
Codeine
Ibuprofen
Other:__________________________
NO KNOWN DRUG ALLERGIES
CHRONIC CONDITIONS OR DISEASES: (PLEASE LIST OR DESCRIBE)
OVER THE COUNTER MEDICAITONS USED REGULARLY: (Please list)
In order for us to provide pharmacy services to you, we require a copy of your Prescription Insurance Card. If you
have a co-pay or uncovered charge(s) the pharmacy will bill your credit card for payment. Please provide credit
card information below. Thank you for your cooperation.
CARSON LONG MILITARY ACADEMY
Emergency Medical Information
Cadet: _________________________________SSN:____-_____-_______ DOB: _________
FOOD/DRUG ALLERGIES: __________________________________________________
IMPORTANT MEDICAL INFORMATION: ____________________________________
______________________________________________________________________________
______________________________________________________________________________
ROUTINE MEDICATION/DOSAGES:
MEDICATION
DOSAGE
MEDICATION
FAMILY/PRESCIRBING PHYSICIAN:
NAME:
PARENT
DOSAGE
PHONE: ( )
LEGAL GUARDIN (CHECK ONE)
Name:
Email:
Address:
City:
State:
Home:
Work:
Mobile:
INSURANCE INFORMATION
Insurance Company
Policy Holder Name
Preauthorization required?
Yes
No
Date of Birth
Phone #
City
State/Zip
Social Security Number
Employer
Address:
Credit Card Information (To be used for cadet’s medical co-pay/expenses not covered by insurance)
This information will be obtained by the providing facility at the time of service. Be informed that you will
receive a call for your card information by that provider and if you want to verify a provider just contact
the nurse if you have not already heard from us. 717-582-2518 is the nurse’s office
Signature of
Parent/Guardian____________________________________________________Date:__________________
CARSON LONG MILITARY ACADEMY
NEW BLOOMFIELD, PENNSYLVANIA 17068
(717) 582-2518 Infirmary
(717) 582-2121 Office
(717) 582-2518 Infirmary Fax
CADET HEALTH RECORD
PLEASE TYPE OR PRINT
Name ______________________________________________________________________________________________________ _
(Last Name)
(First Name)
(Middle Name)
Age _________ Date of Birth _________________________________________ Social Security Number ______________________
Parents/Guardian _______________________________________________________________________________________________ _
Address _____________________________________________________________________________________________________ _
Home Phone # _____________________________ Father's Bus. # ________________________ Mother's Bus. # _______________ _
Father's Cell Phone # _______________________________ _
Mother's Cell Phone # _____________________________ _
Fax # __________________________ Parent E-Mail Address _______________________________________________________ _
Personal Physician _________________________________________________________________ Phone # ___________________ _
Physician Address ______________________________________________________________________________________________ _
List the name of your MEDICAL INSURANCE COMPANY: _________________________________________________________ _
Policy # ______________________________ Address ____________________________________ Phone # _____________________ _
Please attach a photocopy of your MEDICAL INSURANCE CARD (both sides). IFYOU DO NOT HAVE MEDICAL INSURANCE, YOU
ARE REQUIRED TO PURCHASE INSURANCE THROUGH THE [LOCAL] MOORE INSURANCE AGENCY.
1. Parental Consent For Medical Treatment and/or Hospitalization:
• I hereby consent to the examination and treatment of the above named student by physicians/physician assistants at Family
Practice Center, (FPC) in the school infirmary, their office, or other facilities as the need may arise.
• I furthermore consent to emergency medical care by treating or consulting physicians or physician extenders in the emergency
room of any hospital, other acute care facility, or physician office.
• I furthermore consent that in the event of an emergency, psychiatric crisis, or suspected drug or alcohol use, Carson Long may seek
immediate examination and treatment at any local treatment facility.
• I furthermore consent to the performance of procedures and tests (including, but not limited to, X-rays, laboratory tests, or drug
and alcohol screening tests), which shall be deemed necessary by the treating or consulting physician.
• I furthermore give permission for staff designated by Carson Long Institute to present the above named student for medical care.
• I furthermore authorize any physician or hospital providing services to bill the above listed insurance company(s) for the
services provided. Additionally authorize the release of protected health information to said companies.
• Finally, I agree to pay the full amount due for any and all services rendered, in a timely manner.
Signed: _______________________________
Parent or Guardians Signature
__________________________
Relationship to Patient
________
Date
2. Parental Authorization for Release of Protected Health Information:
I hereby authorize any treating physician or hospital to release to Carson Long Institute, Family Practice Center, (FPC) and the
personal physician listed above, any and all protected health information, for care, which occurs while the above named person, is a
cadet at Carson Long Institute. This includes history, examinations, laboratory results, imaging studies, consultations, medications,
and patient care instructions. This authorization shall remain in effect until the cadet is no longer enrolled at Carson Long Institute.
SIGNED:
_____________________________________________
(Patient or Guardian's signature)
________________
(Relationship to Patient)
________
(Date)
3. Release of Specially Protected Health Information:
I furthermore authorize the release of specially protected health information, including HIV testing, psychiatric treatment, drug and
alcohol treatment, and sexually transmitted disease treatment to Carson Long Institute, Family Practice Center, F.P.C., and the above
named personal physician.
SIGNED
__________________________________________ _
(Patient or Guardian's signature)
________________________
(Relationship to Patient)
4. Acknowledgment of Family Practice Center,(FPC) Privacy Notice:
I hereby acknowledge the receipt of a copy of the Family Practice Center, (FPC) Notice of Privacy
Practices.
SIGNED
__________________________ _____________________ _____________________
(Patient or Guardian's signature)
(Relationship to Patient)
________
(Date)
________
(Date)
•
MEDICAL EXAMINATION
THE FOLLOWING INFORMATION MUST BE COMPLETED BY A PHYSICIAN
Height: ___________________________ Weight: ____________________
_
Allergies: (medicines, food, environment/include type of
reaction) ________________________________________________________________________________________________________________
History of serious illness or operation:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
History of Tuberculosis: Self ___________________Family__________________Dates of BCG if received ______________________
_
If INH Treatment where: ___________________________ _______________________________ Date completed: _______________
PPD (Required every 2 years) DATE _____________________________Result ___________________________________________ _
If Hx of BCG or Pos PPD CXR required:_____________________________________________________________________________
Scalp: Normal _____________________________
Skin: Normal _______________________
Infected ________________________ Remarks ________________________
Lesions: Communicable _________________________ Other ____________________
Throat/Tonsils: Normal ________________________________Throat Culture (If necessary} ________________________________
Ears: Normal _______________________________ Remarks ___________________________________________________________
Hearing: Audiometer Right____________________ Left ______________________ ____ Threshold test ________________________
Pure tone Only________________________
Remarks
Note highest decibel loss frequency:_________________________________________________________________________________
_______________________________________________________________________________________________________________
Mouth: Mucous membrane ___________________________________________ _______ Speech________________________________
Pulse: ____________Resp.: _______________Temp.: ________________ ____ Remarks _____________________________________
Heart: Normal __________________ _ Abnormal _________________ Murmur: Physiologic___________ Pathologic ______________
Blood Pressure: Systolic _________________ Diastolic _________________ Remarks _____________________________________
Lungs: Percussion______________________ _ Auscultation _______________ Cough_____________________________________
Remarks ______________________________________________________________________________________________________
_
Neuro Psychiatric: Symptoms of nervous disease _____________________________________________________________________ _ _
Reflexes ______________________________ Remarks ______________________________________________________________ __ _
Remarks ____________________________ _
Gastrointestinal: _________________________
Hernia ______________________
Abdomen:_______________________Remarks_
__________________________________________________________________
Genitourinary:
Urinalysis_____________Sugar________________Albumin_________Micro________
_
_
Remarks ____________________________________________________________________________________________________ __ _
Orthopedic defects: Remarks _____________________________________________________________________________________
Scoliosis check (Required for all 6th & 12th grade students) ________________________________________________________
Are there any limitations to exercises or long-distance hiking? _______________________________________________________
Remarks _____________________________________________________________________________________________________
_
Metabolic/Endocrine: ___________________________________ Remarks _______________________________________________
_
_______________
Psychiatric/Emotional Background
Has there ever been treatment for psychiatric/emotional problems? __________________
When_____________________________________________________
If yes please explain in detail:__________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List any medication and dose past and present: _____________________________________________ _
Duration of Treatment: ________________________________________________________________ __
_
Is treatment ongoing? _________________________________________________________________
If yes, please attach plan for treatment while at school.
Additional Remarks/Current Problems:___________________________________________________ ______
LABS REQUIRED FOR ALL CADETS (new and old): CBC, Urinalysis, HIV / AIDS Testing. Copies of
reports MUST be attached to physical examination form.
Required by STATE LAW upon initial admission (for new Cadets only) - BLANKS MUST BE COMPLETE
ON THIS FORM.
1. Second dose of MMR (measles vaccine)
Date___________
_
Or titre results attached
2.Date of last Tetanus booster________________(must be within the last 5 years)
Update if needed, date ____________
_
3.Date of Chicken pox illness___________________
_
Or date of Varicella Virus Vaccine#1_________ #2______________________
4.Dates of Hepatitis B Virus Vaccines
__________________
/______________________/_____________________________
5. Meningococcal Conjugate Vaccine (MCV) _______________________________________________
Please list all medications taking at present, and attach administration directions with your signature:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Physician's Signature ________________________________________
Physician's Typed or Printed Name______________________________ _
Address ____________________________________________________
___________________________________________________________
Phone Number (
) ______________________________________
Date:_______________________
EYE EXAMINATION
Eyes: Strabismus: ______________________ _ other defects ____________________
_
VISION 20 Feet
Infection ____________________________ __Remarks _______________________ _
Pupillary reflex: Light _______________ Accommodation _____________________ _
Without
Glasses
Additional
Remarks ________________________________________________________________
________
With
Glasses
_______________________________________________________________________
R
L
Both
R
L
Both
_______________________________________________________________________
Please provide a copy of current prescription. Bring spare pair of glasses.
______________________________________
(Signature of Optometrist/Ophthalmologist)
_________________________________________ __ _
(Address of Optometrist/Ophthalmologist)
_____________________________________________
Printed Name of
Phone Number: (
)
Optometrist/Ophthalmologist)
****************************************** **********************
DENTAL EXAMINATION
This is to certify that the student whose name appears on page I of the Cadet Health Record form –
Is under my care for dental treatment.
Has completed dental treatment.
__________________________________
_____________________________________
(Signature of Dentist)
Address of Dentist
_____________________________________
Printed Name of Dentist
_______
Phone Number
____________________________
Date
CLMA &/OR PENNSYLVANIA STATE LAW REQUIRES BEFORE REGISTRATION DAY:
That your son has a complete physical examination each year before reporting to school. Physical form must be completed and
signed by a licensed physician. (See pages 2 and 3)
2. That your son must have his teeth and eyes examined before reporting to school. (See page 4.)
3.
That a complete record of immunizations - including MONTH, DAY and YEAR - be presented as follows subject to current PA
laws:
a. 4 doses of DPT, TD or DT Vaccine (for protection against tetanus and diphtheria.)
b. 3 doses of Oral Polio Vaccine or, if prescribed by a physician, 4 doses of Salk (injectable) Polio Vaccine.
(Students 18 years of age or older are exempt.)
c. The following Vaccines administered at 12 months of age or older and properly spaced: (1) 2
doses of live Attenuated Measles Vaccine or a blood test showing immunity.
(2)1 doses of live Rubella (German measles) Vaccine or a blood test showing immunity.
(3) 2 doses of live Mumps Vaccine or a signed statement from your physician stating that your child had the disease. (4) Pa.
Dept. of Health requires MMR II Vaccine.
d. Complete Hepatitis B Virus Vaccine completed. (3 doses)
e. Second dose of Varicella or have had disease.
f. A State Immunization Card is attached for this information. Failure to comply will result in denial of your son's admission to
this school. (Must be completed for all new cadets.)
g. Additional for 7th grade 1 dose of MCV and 1 dose of Tdap
1.
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