State Of Florida School Entry Health Exam - Health First Network
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School Entry Health Exam
To Parent/Guardian: Please complete and sign Part I — Child’s Medical History.
State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determined
by local school districts.
(Please Print)
Name of Child (Last, First, Middle)
Birth Date
Sex
Address (Street)
School
Grade
City and ZIP Code
Home Telephone Number
Parent/Guardian (Last, First, Middle)
PART I — CHILD’S MEDICAL HISTORY
To Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left.
(Please explain any “Yes” answers in the space provided below.)
1. Yes
No
Any concerns about general health (eating and sleeping habits, weight, etc.)?
2. Yes
No
Any other specific illness or social/emotional or behavioral problems?
3. Yes
No
Any allergies (food, insects, medication, etc.)?
4. Yes
No
Any prescription medication (daily or occasionally)?
5. Yes
No
Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?
6. Yes
No
Any hospitalization, operation, or major illness (specify problem)?
7. Yes
No
Any significant injury or accident (specify problem)?
8. Yes
No
Would you like to discuss anything about your child’s health with a school nurse?
To Parent/Guardian: Please explain any “Yes” answers from above.
I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this form
provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing
school health services in the district for the limited purpose of meeting my child's health and educational needs.
Ö
Signature of Parent/Guardian
Date
Partnership for School Readiness Recommendations for Prekindergarten and Kindergarten
To Parent/Guardian: Please obtain the services listed below in order to find any problems. Please work with your health care provider to
correct or treat any problems that may reduce your child’s ability to learn in school. (These services are recommended but not required.)
1. Comprehensive Vision Examination (3-5 years of age)
Please describe any corrective action for any problems detected
Date of Exam:
and any accommodations required.
Results of Exam:
Health Care Provider:
(check one) Optometrist
Ophthalmologist
2. Comprehensive Dental Examination
Please describe any corrective action for any problems detected
Date of Exam:
and any accommodations required.
Results of Exam:
Dentist:
3. Hearing Screening
Please describe any corrective action for any problems detected
Date of Exam:
and any accommodations required.
Results of Exam:
Health Care Provider:
DH 3040, 6/02 (Obsoletes previous editions which may not be used) Stock Number: 5744-000-3040-2
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