Health Appraisal Form printable pdf download

+($/7+ $335$,6$/ )250

Name:

Date of Birth:

‰ ‰ ‰ ‰

School:

Gender:

Grade:

,0081,=$7,216 +($/7+ +,6725<

❒

Immunization record attached

Sickle Cell Screen:

Positive

Negative

Not done Date:

❒

No immunizations given today

PPD:

Positive

Negative

Not done Date:

❒

Immunizations given since last Health Appraisal:

Elevated Lead:

Yes

Not done Date:

❒

Dental Referral

Yes

Not done Date:

❒

Significant Medical/Surgical History:

See attached

❒

❒ Asthma

Diabetes: ❒ Type 1 ❒ Type 2

Specify current diseases:

Hyperlipidemia

Hypertension

❒ Other:

❒

Allergies:

LIFE THREATENING

Food:

Insect:

Other:

❒

Seasonal

Medication:

3+<6,&$/ (;$0

Height: _______________

Weight: _______________

Blood Pressure: _______________

Date of Exam:

Referral

Vision - without glasses/contact lenses

____ ____ . ____

Body Mass Index:

Weight Status Category (BMI Percentile):

Vision - with glasses/contact lenses

‰ less than 5

‰ 5

‰ 50

through 49

through 84

Vision - Near Point

‰ 85

‰ 95

‰ 99

Hearing ‰ Pass 20 db sc both ears or:

through 94

through 98

and higher

❒ EXAM ENTIRELY NORMAL

❒

Tanner:

II.

III.

IV.

Scoliosis:

Negative

Positive:

Specify any abnormality (use reverse of form if needed):

0(',&$7,216

❒

Medications (list all):

None

Additional medications listed on reverse of form

Name: ____________________________________________________ Dosage/Time: _________________________________________________

If AM dose is missed at home: ________________________________________________________________________________________________

❒

I assess this student to be self-directed

Yes

Student may self carry and self administer medication

Yes

Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency

sheltering is necessary at school or if the morning medication has not been given.

3+<6,&$/ ('8&$7,21 632576 3/$<*5281' :25. 48$/,),&$7,21 &6( &216,'(5$7,21

❒

Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:

___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.

___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

❒

Specify medical accommodations needed for school:

None

❒

Known or suspected disability:

Please monitor

❒

Restrictions:

Please monitor

❒

Protective equipment required:

Athletic Cup

Sport goggles/impact resistant eyewear

Other:

(Stamp below)

Provider’s Signature:

Phone:

Provider’s Name/Address:

Fax:

Parent Signature:

Date:

Health Appraisal Form

Related Articles

Related forms

Related Categories