Health Screen Form Page 2
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2Child’s Name: _________________________
Date: ___________
History of the following:
Y N Description/Concern/Ability to Self-Manage
20.
Respiratory or Breathing
Reoccurring respiratory infections, reactive airway disease (asthma like
symptoms: coughing, wheezing, shortness of breath)? Does child
receive breathing treatments/nebulizer treatments (nebs)/use an inhaler?
Asthma
(Does child have rescue inhaler? How often is it used?)
Chronic Obstructive Pulmonary Disease (COPD)
21.
Sensorimotor
(e.g., Over/Under reacts to sound, light, touch, etc)
22.
Skin or Hair
Rashes, hives, loss of hair, sores that won’t heal, burns, itching, cuts,
bruises, moist/sweaty skin, unusually cool skin, acne
23.
Sleep or Rest
Does child have difficulty falling or staying asleep? Experience sleep
apnea or take sleeping pills? Have excessive fatigue?
24.
Urinary or Bladder
Does child experience burning, increased frequency, dribbling,
incontinence, unable to hold urine or empty bladder, wetting (daytime
or nighttime), is there a strong odor to urine?
25.
Exposure to lice, scabies, bed bugs in past 3 months?
If yes, which one and when?
Treatment Used? Date completed?
26.
Does child use caffeine?
(pop or coffee)
If yes, frequency and amount.
27.
Does child use tobacco/substance abuse
(Alcohol, Illegal
drugs) If yes, frequency and amount.
28.
Is child exposed to second hand smoke?
29.
Is child experiencing any unresolved physical pain?
If yes, was a referral made?
yes
no (explain)
30.
Past medical procedures
31.
Recent Hospitalization dates and reasons:
Mental or Physical health admissions
32.
Date of last physical examination:
Example:School Physical/Annual Physical
33.
ADHD/ Has child been prescribed a new ADHD
If yes, list date prescribed and date of follow up
medication in last 3 months?
appointment:
34.
Mental Health Diagnoses:
Therapist/Nurse/BHIS Staff Recommendations:_____________________________________________________________________
______________________________________________________________________________
Staff Signature:
IHP/Campus Nurse Signature:____________________________________________________ Date Reviewed: _________________
Child’s Medication List
Please identify all medications including birth control as well as supplements
Prescription and OTC Medication & Dosage
What is the medication prescribed for?
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