School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana Page 4
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4Instructions and Definitions/Criteria
This form is to be used for the Louisiana High School Athletic Association (LHSAA) medical history evaluation. It may also
be used as a school entrance and/or general health exam at the local school district’s discretion. If this form is being used
for school entrance, proper immunization documentation is also required. (See below).
Instructions for the Parent/Legal Guardian:
Complete pages 1-2 as instructed. Sign the bottom of page 2. A licensed medical provider must complete Page 3.
Instructions for the Medical Provider:
Review pages 1-2 and complete page 3 as instructed. Sign the bottom of page 3. Attach proper immunization
documentation if this form is being used for school entrance.
Immunization Documentation:
Louisiana State law (R.S. 17:170) requires proper immunization documentation on all students upon entry to
school. Louisiana Immunization Network for Kids Statewide (LINKS) is a statewide, web-based immunization
tracking system, which replaced over 30 years of “pink cards,” collected statewide in public health. It is preferable
to submit the LINKS print out now available in many physician offices. Other acceptable forms include the IMM-1
card that can be obtained from the Louisiana Office of Public Health (OPH)/Immunization Program or other proof
of immunization that includes dates of series with an authorized signature.
Physicians may contact the OPH/Immunization Program at 504-483-1900 to obtain more information on LINKS or
to obtain blank IMM-1 cards. Please note that there will be a time when only the LINKS print out will be accepted
for school entry.
Definitions/Criteria for the Medical Provider:
Anemia Screen (if indicated)
Perform screen if indicated based on history or clinical findings. Louisiana KIDMED (EPSDT) requires periodic
hemoglobin or hematocrit measurement of Medicaid recipients according to the Louisiana KIDMED Periodicity
Schedule that can be found at: The American Academy of
Pediatrics recommendation for anemia screening can be found at:
Click on Policy Statement: Recommendations
on Practice and Ambulatory Medicine (03/01/00).
Urine Screen (if indicated)
Perform screen if indicated based on history or clinical findings. Louisiana KIDMED (EPSDT) requires periodic
urine dipstick of Medicaid recipients according to the Louisiana KIDMED Periodicity Schedule.
Vision Screening (if indicated)
Perform screen if indicated. Louisiana State law (R.S. 17:2112) requires that the school system test the visual
acuity and muscle balance of all students according to the schedule established by the American Academy of
Pediatrics. The law also requires the school system to test every first grader for color perception. Louisiana
KIDMED (EPSDT) requires subjective and objective vision screening of Medicaid recipients according to the
Louisiana KIDMED Periodicity Schedule.
Hearing Screen (if indicated)
Perform screen if indicated. Louisiana State law (R.S. 17:2112) requires that the school system test the hearing of
all students according to the schedule established by the American Academy of Pediatrics using pure tone
audiometer. Louisiana KIDMED (EPSDT) requires subjective and objective hearing screening of Medicaid
recipients according to the Louisiana KIDMED Periodicity Schedule.
Blood Lead Test (if indicated)
Perform screen if indicated. It is recommended by the Centers for Disease Control and Prevention/Childhood
Lead Poisoning Prevention Program that a risk assessment questionnaire is administered at every well baby visit
(6-72 months) and that all children receive a blood lead test at ages 1 and 2, or, if between 3 and 6 years of age
and not previously tested. Louisiana KIDMED (EPSDT) requires all Medicaid recipients receive a blood lead test
at ages 1 and 2, or, if between the ages of 1 and 6 years of age and not previously tested.
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