Oregon School Health Screening Record
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4________________________ ____________________
_______
OREGON SCHOOL HEALTH SCREENING RECORD
Last Name
First
MI
This file shall not include medical or nursing records (ORS 192.525 et seq.)
Health Alert
DOB ______________________ Gender: M _______ F _______
Health Management Plan
ID Number _____________________________
HMP located at ___________________________________________
School District ___________________________________________
Medical/Nursing Records (confidential health information) located
at _______________________________________________________
(requires parent/guardian consent to release)
Demographic Information (may attach label)
REQUIRED
OPTIONAL
School
Gr.
School/City/State
VISION
Hearing*
Height
Weight
Blood
Scoliosis*
Dental*
Screening
Year
Pressure
Comments
Right
Left
Corrective
Lenses
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
*Codes:
N–Normal
R–Referred
UT–Under Treatment
D–Deferred—no referral
See guidelines for screening and referral criteria in Health Services for the School Community (ODE 2010)
OREGON DEPARTMENT OF EDUCATION, Salem, Oregon 97310-1300
Form 581-3417 (11/10)
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