Health Screening Form For Ec Evaluations
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1HEALTH SCREENING FORM
For EC Evaluations
Student:
DOB:
School:
Grade:
Teacher:
1.
Serious Health Condition/Illness (Describe):
Date/Onset
Hospitalized
Yes
No
2.
Accidents (Describe):
Date
Hospitalized
Yes
No
3.
Is this student on any medication taken daily?
Yes
No
If yes: Name/Dosage of Medication
Reason for Medication
4.
Is student sick often?
Yes
No
If yes, why?
Does this student appear to be in good health? (Teacher Observation)
Yes
No
Date of student’s last visit to the doctor:
5.
Reason:
Name of student’s physician:
Dentist:
Does this student have health insurance?
6.
Important Medical History (Circle and explain those that apply)
Allergies (medicine, food, bee/wasp sting):
What happens?
Epi-pen prescribed by doctor:
Asthma…Date of last attack
…Medication needed
Diabetes (Type 1 or Type 2)
Insulin dependent?
Oral medication?
Seizures…Date of last seizure
…Medication needed
Arthritis
Bleeding Problem
Hearing Problems (Hearing Aid
)
Sickle Cell
Kidney Problem
Orthopedic (bone or muscle) Problem
Heart Problem
…
Vision Problem Does he/she wear glasses?
Date of last eye exam:
7.
Vision Screen Results:
with/without glasses
FAR
Rt. 20/
Lt. 20/
Date:
NEAR Rt. 20/
Lt. 20/
Referred to “eye doctor”
Comments:
8.
Parents/Guardians names and phone numbers
Source of information: School Records
Parent/Student Interview
Dr./Medical Records
Other
Referred by School Nurse to
____________________________________________________________
______________
Signature/Title of Person Completing Form
Date
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Parent category: Medical