Kai's Health Assesment

[Hybrid]

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.)?
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.)?
No

Does your child take any medications (daily or occasionally)?
No

Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?
No

Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
No

In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
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]
No

Does your child have health insurance?
No

Does your child have dental insurance?
No

Would you like to discuss anything about your child’s health with the school nurse?
No

Please explain any “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Personal Data - PARENT COMPLETE
Has your child had a dental exam by a dentist in the last 12 months?
No

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:


___Health-Related Recommendations to Enhance School Performance For example: sitting near the front of classroom, special equipment needs.
Please specify:
None.
Physical Examination

Weight (lbs.): 6'4"
Height (ft. in.): 195 Lbs

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


[XI give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.
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