Student Health Assessment Form Original

ASSESSMENT FORM
INFORMATION PROVIDED IS CONFIDENTIAL
PART 1 HEALTH ASSESSMENT STUDENT

MAT. NO
To be completed by Student
Student's Name (Last, First, Middle) Birth date Name of School Grade
(Mo., Day, Yr.)
Address (Number, Street, City, State, Zip) Phone No.
Parent/Guardian Names
Where do you usually go for routine medical care? Phone No.

Name: Address:
When was the last time you had a physical exam? Month Year
When was the last time you had a dental exam? Month Year
Where do you usually go for dental care? Phone No.

Name: Address:
ASSESSMENT OF STUDENT HEALTH
To the best of your knowledge, have you had any of the following health problem? Please tick as appropriate
Yes No Comments
Anaphylaxis
Allergies (Food, Insects, Drugs, Latex)
Allergies (Seasonal)
Asthma or Breathing Problems
Behavior or Emotional Problems
Birth Defects
Bleeding Problems
Cerebral Palsy
Dental
Diabetes
Ear Problem or Deafness
Eye or Vision Problems
Head Injury
Heart Problems
Hospitalization (When, Where, Why)
Lead Poisoning/Exposure
Learning problems/disabilities
Limits on Physical Activity
Meningitis
Prematurity
Problem with Bladder
Problem with Bowels
Problem with Coughing
Seizures
Serious Allergic Reactions
Sickle Cell Disease
Speech Problems
Surgery
Other
Are you on any medication? □ No □ Yes

Name(s) of Medications: ______________________________________________________________________________________________
Do you require any medication to be administered in school? □ No □ Yes
Name(s) of Medications: ______________________________________________________________________________________________
Do you require any emergency medications (epinephrine auto-injectors, inhalers, glucagon, Diastat, nebulized medication) to be administered
in school? □ No □ Yes, please list ______________________________________________________________________
Student Signature Date
PART II SCHOOL HEALTH ASSESSMENT STUDENT MAT. NO

To be completed ONLY by Physician/Nurse Practitioner
Student's Name (Last, First, Middle) Birthdate (Mo., Name of School
Day, Yr.)
1. Have you been diagnosed of any medical condition? □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
2. Do you have any health condition which may require EMERGENCY ACTION while in school? (e.g., seizure, severe allergic reaction/ anaphylaxis to food or
insect sting, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE. Additionally, please “work with the school nurse
to develop an emergency plan”. □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
3. Are there any abnormal findings on evaluation for concern? □ No □ Yes
Specify ___________________________________________________________________________________________________________________________
EVALUATION FINDINGS/CONCERNS
Area of
PHYSICAL EXAM WNL ABNL HEALTH AREA OF CONCERN Yes No
Concern
Head Attention Deficit/Hyperactivity
Eyes Behavior/Adjustment
ENT Development
Dental Hearing
Respiratory Immunodeficiency
Cardiac Lead Exposure/Elevated Lead
GI Learning Disabilities/Problems
GU Mobility
Musculoskeletal/Orthopedic Nutrition
Neurological Physical Illness/Impairment
Skin Psychosocial
Endocrine Speech/Language
Psychosocial Vision
Other
REMARKS: (Please explain any abnormal findings/health concerns.)
4. RECORD OF IMMUNIZATIONS : EDOCNSAF is required to be completed and attached by a health care provider or a computer generated immunization record
must be provided.
5. Is the child on medication? If yes, indicate medication and diagnosis. □ No □ Yes
__________________________________________________________________________________________________________________________________
EDOCNSAF, Authorization to Administer Prescribed Medication, Release and Indemnification Agreement, must be completed for medication administration
in school).
6. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. □ No □ Yes
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
7. Screenings Results Date Taken
Tuberculin Test
Blood Pressure
Height
Weight
BMI %tile
Lead Test Optional
PART II SCHOOL HEALTH ASSESSMENT (continued) To be completed

ONLY by Physician/Nurse Practitioner
(Student Name) ________________________________________________________________________ has had a complete physical examination and has:
□ No evident problem that may affect learning or full school participation □ Problems noted above
Additional Comments:
Physician/Nurse Practitioner (Type or Print) Phone No. Physician/Nurse Practitioner Signature Date

Student Health Assessment Form Original

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ASSESSMENT FORM

INFORMATION PROVIDED IS CONFIDENTIAL

PART 1 HEALTH ASSESSMENT STUDENT

Address (Number, Street, City, State, Zip) Phone No.

Where do you usually go for routine medical care? Phone No.

Where do you usually go for dental care? Phone No.

Allergies (Food, Insects, Drugs, Latex)

Asthma or Breathing Problems

Behavior or Emotional Problems

Ear Problem or Deafness

Eye or Vision Problems

Hospitalization (When, Where, Why)

Problem with Bladder

Problem with Bowels

Problem with Coughing

Serious Allergic Reactions

Sickle Cell Disease

Are you on any medication? □ No □ Yes

Student Signature Date

PART II SCHOOL HEALTH ASSESSMENT STUDENT MAT. NO

1. Have you been diagnosed of any medical condition? □ No □ Yes

Cardiac Lead Exposure/Elevated Lead

Neurological Physical Illness/Impairment

REMARKS: (Please explain any abnormal findings/health concerns.)

Lead Test Optional

PART II SCHOOL HEALTH ASSESSMENT (continued) To be completed

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