Post by xBlink on Aug 3, 2009 13:01:34 GMT -5
Health Assessment Form
Yes, the last mandatory form, for students and teachers alike.
Completition Informatition
Fill out in accordance to the example below. Once you have completed this form submit it to the Office Inbox. When we accept your formit will be added to the Filing Cabinet.
Form:
Yes, the last mandatory form, for students and teachers alike.
Completition Informatition
Fill out in accordance to the example below. Once you have completed this form submit it to the Office Inbox. When we accept your formit will be added to the Filing Cabinet.
Form:
Health Assessment
Part I — to be completed by parent or guardian
Important: Complete Part I before your child is examined.
Take this form with you to the health care provider’s office.
Yes No
(Explain all “yes” answers in the space provided below.)
Do you have any concerns about your child’s general health (overall eating and sleeping habits, teeth, etc.)?
(answer here)
Has your child been diagnosed with any chronic disease?
___asthma
___diabetes
___seizure disorder
___other
___none
Does your child have any allergies (food, insects, medication, latex, etc.)?
(answer here)
Does your child take any medications (daily or occasionally)?
(answer here)
Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?
(answer here)
Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
(answer here)
In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
(answer here)
In the last 12 months, has your child experienced any difficulty with excessive weight loss or weight gain, or excessive thirst or urination?
(Please specify.) [/color]
(answer here)
Does your child have health insurance?
(answer here)
Does your child have dental insurance?
(answer here)
Would you like to discuss anything about your child’s health with the school nurse?
(answer here)
Please explain any “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.
(explain here)
Personal Data - PARENT COMPLETE
Has your child had a dental exam by a dentist in the last 12 months?
(answer here)
Has your child had a well-child visit or check-up in the last 12 months?
(answer here)
HEALTH CARE PROVIDER COMPLETE
___ Requesting School Follow Up
___ No Recommendations, Concerns or Needs
___ Medication
If Checked:
___Child takes medicine for specific health conditions:
List medication(s):
1. (answer here)
3. (answer here)
2. (answer here)
4. (answer here)
___Medication must be given and/or available at school
___Allergy
___Food: (answer here)
___Insect: (answer here)
___Medicine: (answer here)
___Other: (answer here)
Type of allergic reaction (Anaphylaxis, Local reaction):
(answer here)
Response required (Epinephrine Auto-injector, Other [please specify], None):
(answer here)
___Developmental Concerns Identified (See comments below)
___Child needs referral to school support team for further evaluation.
___Special Diet
Guidance:
(answer here)
___Health-Related Recommendations to Enhance School Performance For example: sitting near the front of classroom, special equipment needs.
Please specify:
(answer here)
Physical Examination
Weight (lbs.): (answer here)
Height (ft. in.): (answer here)
Body Mass Index (BMI) - for age:
___Normal (5%ile - <85%ile)
___Underweight (<5%ile)
___At-Risk (85%ile to <95%ile)
___Overweight ( 95%ile)
Blood Pressure:
___Within Normal Range
___> 90 Percentile ( 95%ile)
HEENT (Head, Ears, Eyes, Nose, Throat):
___Normal ___Abnormal
Dental/Oral:
___Normal ___Abnormal
Lungs:
___Normal ___Abnormal
Cardiac:
___Normal ___Abnormal
Abdomen:
___Normal ___Abnormal
Neurological:
___Normal ___Abnormal
Back/Extremities:
___Normal ___Abnormal
Genital:
___Normal ___Abnormal
Skin:
___Normal ___Abnormal
[Put X here]I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.
[/size]
[size=2][b][color=maroon] Health Assessment[/color][/b][/size]
[size=2]Part I — to be completed by parent or guardian[/size][size=1]
[i]Important: Complete Part I before your child is examined.
Take this form with you to the health care provider’s office.[/i]
[b]Yes No[/b]
[i](Explain all “yes” answers in the space provided below.)[/i]
[color=teal]Do you have any concerns about your child’s general health (overall eating and sleeping habits, teeth, etc.)? [/color]
(answer here)
[color=teal]Has your child been diagnosed with any chronic disease? [/color]
___asthma
___diabetes
___seizure disorder
___other
___none
[color=teal]Does your child have any allergies (food, insects, medication, latex, etc.)? [/color]
(answer here)
[color=teal]Does your child take any medications (daily or occasionally)? [/color]
(answer here)
[color=teal]Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?[/color]
(answer here)
[color=teal]Has your child had any hospitalization, operation, major illness or injury, or significant accident? [/color]
[i](Please specify.)[/i]
(answer here)
[color=teal]In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking? [/color]
[i](Please specify.)[/i]
(answer here)
[color=teal]In the last 12 months, has your child experienced any difficulty with excessive weight loss or weight gain, or excessive thirst or urination? [/color]
(Please specify.) [/color]
(answer here)
[color=teal]Does your child have health insurance? [/color]
(answer here)
[color=teal]Does your child have dental insurance? [/color]
(answer here)
[color=teal]Would you like to discuss anything about your child’s health with the school nurse? [/color]
(answer here)
[color=teal]Please explain any “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time. [/color]
(explain here)
[u]Personal Data - PARENT COMPLETE[/u]
[color=teal]Has your child had a dental exam by a dentist in the last 12 months? [/color]
(answer here)
[color=teal]Has your child had a well-child visit or check-up in the last 12 months? [/color]
(answer here)
[u]HEALTH CARE PROVIDER COMPLETE[/u]
[color=teal][b]___ Requesting School Follow Up[/b] [/color]
[color=teal][b]___ No Recommendations, Concerns or Needs[/b] [/color]
[color=teal][b]___ Medication[/b] [/color]
If Checked:
[color=teal]___Child takes medicine for specific health conditions: [/color]
[color=teal]List medication(s): [/color]
[color=teal]1. [/color] (answer here)
[color=teal]3. [/color] (answer here)
[color=teal]2. [/color] (answer here)
[color=teal]4. [/color] (answer here)
___Medication must be given and/or available at school
[color=teal][b]___Allergy[/b] [/color]
___Food: (answer here)
___Insect: (answer here)
___Medicine: (answer here)
___Other: (answer here)
[color=teal]Type of allergic reaction (Anaphylaxis, Local reaction): [/color]
(answer here)
[color=teal]Response required (Epinephrine Auto-injector, Other [please specify], None): [/color]
(answer here)
[color=teal][b]___Developmental Concerns Identified (See comments below)[/b] [/color]
[color=teal]___Child needs referral to school support team for further evaluation. [/color]
[color=teal][b]___Special Diet[/b] [/color]
[color=teal]Guidance: [/color]
(answer here)
[color=teal][b]___Health-Related Recommendations to Enhance School Performance[/b][i] For example: sitting near the front of classroom, special equipment needs.[/i] [/color]
[color=teal]Please specify: [/color]
(answer here)
[u]Physical Examination [/u]
[color=teal][b]Weight[/b] (lbs.): [/color] (answer here)
[color=teal][b]Height[/b] (ft. in.): [/color] (answer here)
[color=teal][b]Body Mass Index (BMI) - for age:[/b] [/color]
___Normal (5%ile - <85%ile)
___Underweight (<5%ile)
___At-Risk (85%ile to <95%ile)
___Overweight ( 95%ile)
[color=teal][b]Blood Pressure: [/b][/color]
___Within Normal Range
___> 90 Percentile ( 95%ile)
[color=teal]HEENT (Head, Ears, Eyes, Nose, Throat): [/color]
___Normal ___Abnormal
[color=teal]Dental/Oral: [/color]
___Normal ___Abnormal
[color=teal]Lungs: [/color]
___Normal ___Abnormal
[color=teal]Cardiac: [/color]
___Normal ___Abnormal
[color=teal]Abdomen: [/color]
___Normal ___Abnormal
[color=teal]Neurological: [/color]
___Normal ___Abnormal
[color=teal]Back/Extremities: [/color]
___Normal ___Abnormal
[color=teal]Genital: [/color]
___Normal ___Abnormal
[color=teal]Skin:[/color]
___Normal ___Abnormal
[Put X here]I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.
[/size]