State Of Connecticut Department Of Education - Health Assessment Record printable pdf download

State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests

information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine, an

advanced practice registered nurse or registered nurse, a physician assistant or the school medical advisor prior to school entrance in

Connecticut (C.G.S. Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th

grade and in the 10th or 11th grade. Specific grade level will be determined by the local board of education.

Please print

Social Security Number

Birth Date

Name of Student

Sex

(Last, First, Middle)

Race/Ethnicity

Address

(Street)

❑

American Indian

White, not of Hispanic origin

❑

Asian

Hispanic/Latino

(Town and ZIP code)

❑

Black, not of Hispanic origin

Other

Home Telephone Number

School

Grade

Name of Parent/Guardian

(Last, First, Middle)

Health Care Provider

Health Insurance Company/Number* or Medicaid/Number*

* If applicable

If your child does not have health insurance, call 1-877-CT-HUSKY

Part I — To be completed by parent

Important: Complete Part I before your child is examined.

Take this form with you to the health care provider’s office.

Please check answers to the following questions in columns on the left.

(Explain all “yes” answers in the space provided below.)

Yes No

1. ❑

❑

Do you have any concerns about your child’s general health (overall eating and sleeping habits, teeth, etc.)?

2. ❑

❑

❑ asthma ❑ diabetes ❑ seizure disorder ❑ other

Has your child been diagnosed with any chronic disease

3. ❑

❑

Does your child have any allergies (food, insects, medication, latex, etc.)?

4. ❑

❑

Does your child take any medications (daily or occasionally)?

5. ❑

❑

Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?

6. ❑

❑

Has your child had any hospitalization, operation, major illness or injury, or significant accident? (Please specify.)

7. ❑

❑

In the last 12 months, has your child experienced any difficulty with wheezing, excessive coughing or excessive night waking?

(Please specify.)

8. ❑

❑

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.)

9. ❑

❑

Does your child have health insurance? (If your child does not have health insurance, call 1-877-CT-HUSKY)

10. ❑

❑

Does your child have dental insurance?

11. ❑

❑

Would you like to discuss anything about your child’s health with the school nurse?

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

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

Signature of Parent/Guardian

Date

HAR-3

To be maintained in the student’s Cumulative School Health Record

REV. 4/2006

State Of Connecticut Department Of Education - Health Assessment Record

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