Kindergarten Physical Form

REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY

To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information.

If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health
department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.

CHDP website: www.dhcs.ca.gov/services/chdp

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