Form Pps-2k - North Carolina Kindergarten Health Assessment Form (Spanish)
Download a blank fillable Form Pps-2k - North Carolina Kindergarten Health Assessment Form (Spanish) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Pps-2k - North Carolina Kindergarten Health Assessment Form (Spanish) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2NORTH CAROLINA
PPS-2K Rev. 1/11
KINDERGARTEN HEALTH ASSESSMENT REPORT
Evaluación de Salud de Niños en edad de Asistir al Kindergarten
(Approved by North Carolina Department of Public Instruction and Department of Health and Human Services)
Personal Data
*Please bring your child's shot records with you to this visit *
-
Por favor, escriba claramente
Vea al dorso la información adicional requerida. Por favor, presente el formulario completado a la escuela de su niño/niña.
Nombre del niño/niña
(Apellido)
(Primer)
(Segundo)
Fecha de nacimiento:
/
/ 20
(mm/dd/aaaa)
Dirección:
Ciudad:
Estado:
Código postal:
Nombre del padre o tutor legal:
Teléfono:
Si
No
¿Tiene alguna preocupación sobre la salud, peso, desarrollo o conducta de su niño?
¿Sufre algún miembro de su familia alguna enfermedad que ha afectado su salud, peso,
desarrollo o conducta? (Por favor, explíquelo en la sección de comentarios)
¿Ha visto a su niño algún proveedor por alguna preocupación con su salud, peso, desarrollo o conducta?
¿Ha tenido su niño una evaluación dental en los últimos 12 meses?
¿Ha tenido su niño una consulta de salud con un médico en los últimos 12 meses?
Comentarios:
Consentimiento de los padres: Estoy de acuerdo con que el proveedor de atención médica y el personal de la escuela de mi niño
conversen sobre la información de este formulario y permita que el Departamento de Salud y Servicios Humanos recolecten y
analicen la información de este formulario para entender mejor las necesidades de salud de los niños en Carolina del Norte.
Firma: _______________________________________ Fecha: _________
Recommendations to School Personnel Based on Health Assessment
No Recommendations, Concerns or Needs
Requesting School Follow Up
Medication
Child takes medicine for specific health conditions:
List medication(s): 1.
3.
2.
4.
Medication must be given and/or available at school
Allergy
Food:
Insect:
Medicine:
Other:
Type of allergic reaction:
Anaphylaxis
Local reaction
Response required:
Epinephrine Auto-injector
Other:
None
Developmental Concerns Identified (See comments below)
Child needs referral to school support team for further evaluation.
Special Diet
Guidance:
Health-Related Recommendations to Enhance School Performance
For example: sitting near the front of classroom, special equipment needs.
Please specify:
School Health Forms Attached
School Medication Authorization Form
Diabetes Care Plan
Asthma Action Plan
Health Care Plan(s) List Condition
Comments:
Was this assessment completed in the child's regular health care provider's office?
yes
no
If no , please provide a copy to the child's parent to give to the child's regular health care provider.
Health Care Professional's Certification
- Attach a copy of the immunization record
.
I certify that the information on this form is accurate and complete to the best of my knowledge.
Provider's Name:
Provider Stamp Here
Provider's Signature:_______________________________ Date: _________
Practice/Clinic Name:
Practice/Clinic Address:
Practice/Clinic City, State & Zip:
Practice Phone:
Fax:
-Front-
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dma-3066 - Independent Assessment Request For New Admissions - North Carolina Department Of Health And Human Services
Legal
Form Dma 3051 - Request For Independent Assessment For Personal Care Services (pcs) Attestation Of Medical Need - North Carolina Department Of Health And Human Services
Legal
Related Categories
Parent category: Legal