Post by faith on Mar 24, 2010 22:49:32 GMT -5
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)
no
Has your child been diagnosed with any chronic disease?
___asthma
___diabetes
___seizure disorder
___other
__x_none
Does your child have any allergies (food, insects, medication, latex, etc.)?
(answer here)
no
Does your child take any medications (daily or occasionally)?
(answer here)
no
Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?
(answer here)
no
Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
(answer here)
Had to go to the hospital for a stress attack 4 months ago
In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
(answer here)
no
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)
no
Does your child have health insurance?
(answer here)
yes
Does your child have dental insurance?
(answer here)
yes
Would you like to discuss anything about your child’s health with the school nurse?
(answer here)
yes at time there seems to another person in her
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)
yes
Has your child had a well-child visit or check-up in the last 12 months?
(answer here) yes
HEALTH CARE PROVIDER COMPLETE
___ Requesting School Follow Up
__x_ 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) 144
Height (ft. in.): (answer here)5'11 ( the male is 6'1)
Body Mass Index (BMI) - for age:
_x__Normal (5%ile - <85%ile)
___Underweight (<5%ile)
___At-Risk (85%ile to <95%ile)
___Overweight ( 95%ile)
Blood Pressure:
__x_Within Normal Range
___> 90 Percentile ( 95%ile)
HEENT (Head, Ears, Eyes, Nose, Throat):
__x_Normal ___Abnormal
Dental/Oral:
_x__Normal ___Abnormal
Lungs:
_x__Normal ___Abnormal
Cardiac:
_x__Normal ___Abnormal
Abdomen:
__x_Normal ___Abnormal
Neurological:
__x_Normal ___Abnormal
Back/Extremities:
__x_Normal ___Abnormal
Genital:
__x_Normal ___Abnormal
Skin:
_x__Normal ___Abnormal
[X]I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.
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)
no
Has your child been diagnosed with any chronic disease?
___asthma
___diabetes
___seizure disorder
___other
__x_none
Does your child have any allergies (food, insects, medication, latex, etc.)?
(answer here)
no
Does your child take any medications (daily or occasionally)?
(answer here)
no
Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?
(answer here)
no
Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
(answer here)
Had to go to the hospital for a stress attack 4 months ago
In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
(answer here)
no
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)
no
Does your child have health insurance?
(answer here)
yes
Does your child have dental insurance?
(answer here)
yes
Would you like to discuss anything about your child’s health with the school nurse?
(answer here)
yes at time there seems to another person in her
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)
yes
Has your child had a well-child visit or check-up in the last 12 months?
(answer here) yes
HEALTH CARE PROVIDER COMPLETE
___ Requesting School Follow Up
__x_ 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) 144
Height (ft. in.): (answer here)5'11 ( the male is 6'1)
Body Mass Index (BMI) - for age:
_x__Normal (5%ile - <85%ile)
___Underweight (<5%ile)
___At-Risk (85%ile to <95%ile)
___Overweight ( 95%ile)
Blood Pressure:
__x_Within Normal Range
___> 90 Percentile ( 95%ile)
HEENT (Head, Ears, Eyes, Nose, Throat):
__x_Normal ___Abnormal
Dental/Oral:
_x__Normal ___Abnormal
Lungs:
_x__Normal ___Abnormal
Cardiac:
_x__Normal ___Abnormal
Abdomen:
__x_Normal ___Abnormal
Neurological:
__x_Normal ___Abnormal
Back/Extremities:
__x_Normal ___Abnormal
Genital:
__x_Normal ___Abnormal
Skin:
_x__Normal ___Abnormal
[X]I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.