Health Assessment Form For Compliance With K.s.a. 72-5214 printable pdf download

Health Assessment Form For Compliance With K.s.a. 72-5214

HEALTH ASSESSMENT FORM

FOR COMPLIANCE WITH K.S.A. 72-5214

(Health Assessment at School Entry)

I hereby consent for my child, __________________________________________

to receive a health assessment screening.

I understand that this screening includes:

hearing, vision, dental, lead, urinalysis, hemoglobin/hematocrit, nutrition, developmental,

health history, and a complete physical examination.

If the HEALTH ASSESSMENT FOR CHILDREN AND YOUTH form is used for

school entry, a copy should accompany the student to school.

_____________________________________

Parent/Guardian

_________________________

Date

Do not write below this line

--------------------------------------------------------------------------------------------------------------------------------------------

I certify that _____________________________________ has completed the

Child’s Name

health assessment required by Kansas Law.

_______________________________________

Health Care Provider

________________________

Date

Complete and attach this section only if parent refuses to sign consent on Health Assessment for Children and Youth.

Health Assessment Form For Compliance With K.s.a. 72-5214