Post by xBlink on Mar 27, 2010 23:19:20 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.)?
He often gets really tired and if it’s sunny outside, we would greatly appreciate it if you would let him sleep in class, as long as he isn’t distracting anyone..
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)?
Nope.
Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
Nope. Not recently.
In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
Nope.
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]
Nope.
Does your child have health insurance?
Yep.
Does your child have dental insurance?
Yep
Would you like to discuss anything about your child’s health with the school nurse?
Nope.
Please explain any “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.
N/A
Personal Data - PARENT COMPLETE
Has your child had a dental exam by a dentist in the last 12 months?
Yes
Has your child had a well-child visit or check-up in the last 12 months?
Yes
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.
3.
2.
4.
___Medication must be given and/or available at school
___Allergy
___Food:
___Insect:
___Medicine:
___Other:
Type of allergic reaction (Anaphylaxis, Local reaction):
None
Response required (Epinephrine Auto-injector, Other [please specify], None):
None
___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:
Physical Examination
Weight (lbs.): 130
Height (ft. in.): 5’8
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
[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.
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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.)?
He often gets really tired and if it’s sunny outside, we would greatly appreciate it if you would let him sleep in class, as long as he isn’t distracting anyone..
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)?
Nope.
Has your child had any hospitalization, operation, major illness or injury, or significant accident?
(Please specify.)
Nope. Not recently.
In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?
(Please specify.)
Nope.
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]
Nope.
Does your child have health insurance?
Yep.
Does your child have dental insurance?
Yep
Would you like to discuss anything about your child’s health with the school nurse?
Nope.
Please explain any “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.
N/A
Personal Data - PARENT COMPLETE
Has your child had a dental exam by a dentist in the last 12 months?
Yes
Has your child had a well-child visit or check-up in the last 12 months?
Yes
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.
3.
2.
4.
___Medication must be given and/or available at school
___Allergy
___Food:
___Insect:
___Medicine:
___Other:
Type of allergic reaction (Anaphylaxis, Local reaction):
None
Response required (Epinephrine Auto-injector, Other [please specify], None):
None
___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:
Physical Examination
Weight (lbs.): 130
Height (ft. in.): 5’8
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
[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.
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