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Massachusetts School Health Record: Provider Exam Form

Massachusetts law (M.G.L. c.71, s.57) requires students to have physical examinations at set intervals, and the results must be shared with the school for the student's health record. The Department of Public Health designed this single-page form so providers report what the school needs for the student's health and safety, from allergies and asthma plans to screenings and sports participation.

Who completes it

The examining MD, DO, NP or PA completes the whole form, circles their credential and signs it. Parents and school nurses do not complete any part.

Submitting and payment

How to submit it
The completed form, together with the student's immunization certificate, is given to the school nurse for the student's health record, often through the parent.
Who pays
The form sets no fee and does not address payment for the school physical.

Good to know

  • Current health issues include allergies with any anaphylaxis history and EpiPen use, asthma (with an Asthma Action Plan attached), diabetes type, seizure disorder and other conditions.
  • Medications given at school should be circled, and the form notes that a separate medication order form is needed for each medication administered in school.
  • Screening boxes cover vision for each eye and stereopsis, hearing for each ear, postural screening for scoliosis, kyphosis or lordosis, and lead results.
  • Targeted TB testing is recorded only for medium-to-high risk students (TST or IGRA with result); low-risk students are checked as no test done.

Get the official form

Download the current version from the source each time; forms change without notice.

Massachusetts School Health Record: Health Care Provider's Examination

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can a provider use their own EHR exam form instead of the Massachusetts form?

Yes. A DPH memorandum says a different form or format is acceptable as long as it includes the content of the Massachusetts Health Care Provider's Examination Form. A separate order for each school medication and an asthma action plan, when relevant, should still be attached.

Does the Massachusetts school exam form clear students for sports?

The form asks whether the student may participate fully in the school program, including physical education and competitive sports, and asks the provider to list restrictions if not. It also asks whether immunizations are complete, with the immunization certificate attached.

What should be attached to the Massachusetts school health record exam?

DPH asks for the student's complete immunization record or certificate, a separate provider's order for each medication or treatment given at school, a Massachusetts Asthma Action Plan for students with asthma, and any detailed information needed for care at school.