Form Pps-2k - North Carolina Kindergarten Health Assessment Report Form
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2PPS-2K Rev. 1/08
NORTH CAROLINA
KINDERGARTEN HEALTH ASSESSMENT REPORT
(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 *
Please Print Clearly - See other side for more required information
Child's Name
(Last)
(First)
(Middle)
_____
Birth Date:
/
/ 20
(mm/dd/yyyy)
Address:
City:
State:
Zip:
Parent/Guardian Name:
Phone:
No
Yes
Are you concerned about your child's health, weight, development or behavior?
Does anyone in your family have a condition that has affected their health, weight, development or
behavior? (Please explain in the comments section)
Has your child been seen by a provider for any health, weight, development or behavior concern?
Has your child had a dental exam by a dentist in the last 12 months?
Has your child had a well-child visit or check-up in the last 12 months?
Comments:
Parental Consent: I agree to allow my child's health care provider and school personnel to discuss information on this form
and allow the Department of Health and Human Services to collect and analyze information from this form to better
understand health needs of children in NC.
Signature: _______________________________________ Date:_________
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-
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Parent category: Medical