Form H.10.1 - Health Assessment

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HEALTH ASSESSMENT
AUGUST 2001
H.10.1
"Insert Name of School"
Office of the School Nurse
Health Assessment
STUDENT: ________________________________________BIRTHDATE:_____________________
TEACHER/GRADE:_________________________________________________________________
VISION: Date Screened __________________________
WITHOUT GLASSES
WITH GLASSES
Distance:
R 20/______ L 20/______
R 20/______ L 20/______
Near:
R 20/______ L 20/______
R 20/______ L 20/______
Instrument used: [
] Titmus [
] Random Letter [
] Tumbling E [
] Pre-school symbols
PERRLAEOM__________
REMARKS:________________________________________________________________________
HEARING: Date Screened_____________________
Testing frequencies @ 20 or 25 dB. Indicate dB at which student heard sound.
2000
4000
500
1000
Right
Left
Canals: [
] pink [
] erythema TM's: [
] clear [
] opaque [
] PE tubes
Remarks:
MEDICAL HISTORY:
___ Review of School Health Record
___ Parent Interview (Social Family Medical History)
___ Review of Medical Records
CURRENT INFORMATION:
Medications:_____________________________________________________________________
Minor Neurological signs: [
] achieved
[
] difficulty with ________________________________
Height: ______inches (
% )
Weight:______pounds (
%)
RELATIONSHIP OF FINDINGS TO EDUCATIONAL FUNCTIONING:
______Vision WITHIN NORMAL LIMITS
______Hearing WITHIN NORMAL LIMITS
______Findings should NOT adversely affect classroom performance.
______Findings should NOY adversely affect one-to-one testing.
______Findings may adversely affect one-to-one testing.
______Findings may adversely affect classroom performance.
RECOMMENDATION: [
] Proceed with testing. [
] Hold testing until:___________________
COMMENTS:
Name, Title and Date
123

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