State Of Connecticut Department Of Education - Health Assessment Record Page 2
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1
2Part II — Medical Evaluation
HAR-3
REV. 4/2006
To the Health Care Provider: Please complete and sign.
has had a complete history and physical exam on
Month/Day/Year
Birth Date
Student’s Name
Findings for this student are as follows:
Screening/Test Results
Immunization Record
Note:
* Mandated Screening/T
est under Connecticut State Law
Vaccine (Month/Day/Year) Note: * Minimum requirements prior
BMI:
* Height:
to school enrollment. At subsequent exams, note booster shots only.
* Weight:
* Postural:
Dose 1
Dose 2
Dose 3
Dose 4
Dose 5
Dose 6
❑ Normal
*
*
*
*
* Blood Pressure:
DTP
❑ Abnormal
DTP/Hib
Pulse:
Min.
____________
DTaP
* HCT/HGB:
Slight
____________
DT/Td
Urinalysis:
Mod.
____________
*
*
*
OPV
* Gross dental:
*
*
*
Marked ____________
IPV
❑ Referral
MMR
Lead
(Date/Result)
*
*
Measles
Booster for entry into K and 7th grade
TB and Other Test Results (Sickle Cell, etc.)
*
Mumps
❑ Yes
❑ No
TB: In high-risk group?
*
Rubella
Test
Date
Results
*
HIB
Students under age 5
Req. for entry into
*
*
*
Hep B
K and 7th grade.
*
Students born 1/1/97 or later.
Varicella
* Vision/ Type of Screening
* Auditory/ Type of Screening
Required for 7th grade entry.
Pneumococcal
PCV
conjugate vaccine
Pass/Fail
With glasses
R
L
Other Vaccines (Specify)
R
20/
20/
R
L
Without glasses
L
20/
20/
* Chronic Disease Assessment:
Date of
Disease Hx
Yes No
onset
of above
❑
❑
Asthma: ❑ mild ❑ moderate ❑ severe
(Date)
(Confirmed by)
(Specify)
❑ exercise induced
❑ unclassified
Exemption
❑
❑
Diabetes: ❑ Type I ❑ Type II
Religious _____
Medical: Permanent _____
Temporary _____
Date _____
❑
❑
Anaphylactic Reaction: ❑ food ❑ insect ❑ latex
❑
❑
Seizure Disorder
Recertify Date _________
Recertify Date _________
Recertify Date ________
❑
❑
Other: Please specify
This student has the following problems which may adversely affect his or her educational experience:
❑ Vision
❑ Auditory
❑ Speech/Language
❑ Physical Dysfunction
❑ Emotional/Social
❑ Behavior
❑ The pupil has a health condition which may require emergency action at school, e.g., seizures, allergies, anaphylaxis. Specify below.
❑ The pupil is on long-term medication. Specify below.
Comments and recommendations (additional information about any of the above health assessment):
❑ This student may participate fully in the school program, including physical education activities.
❑ This student may participate in the school program and physical education with the following restriction/adaptation.
(Specify reason and restriction.)
❑ Yes ❑ No
Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.
❑ I would like to discuss information in this report with the school nurse.
Signature of health care provider
Name/Group Practice (Please type or print.)
Phone Number
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