Health Inventory Form Page 3
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4PART II - SCHOOL HEALTH ASSESSMENT
To be completed ONLY by Physician/Nurse Practitioner
Student’s Name (Last, First, Middle)
Birthdate
Sex
Name of School
Grade
(Mo. Day Yr.)
(M/F)
1. Does the child have a diagnosed medical condition?
No
Yes
_____________________________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________________________________________________
2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school?
(e.g., seizure, insect sting allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes,
please DESCRIBE. Additionally, please “work with your school nurse to develop an emergency plan”.
No
Yes
______________________________________________________________________________________
_____________________________________________________________________________________________________
3. Are there any abnormal findings on evaluation for concern?
Evaluation Findings/CONCERNS
Area of
Physical Exam
WNL
ABNL
Concern
Health Area of Concern
YES
NO
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
R EMARKS: (Please explain any abnormal findings.)
4. RECORD OF IMMUNIZATIONS – DHMH 896 is required to be completed 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
(A medication administration form 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
Maryland Schools -Record of Physical Examination Revised 12/04
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