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Professional School Nurse Health Form

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Plainfield Public Schools

Intervention and Referral Services

PROFESSIONAL SCHOOL NURSE HEALTH FORM

Student: __________________

School: _____________

DOB: ______________

Grade Level: ______________

Room Number:

Please complete and return this form by:

To:

Health History

☐Yes

☐No

Is the student currently taking any medication?

If yes please explain unless information should remain confidential:

☐Yes

☐No

Are you aware of any prior use of medication by the student?

If yes please explain unless information should remain confidential:

Are you aware of any medical or other condition that could interfere with the student’s ability to perform in

☐Yes

☐No

school?

If yes please describe the condition and its implications unless this information should remain confidential:

Health Assessment

Height: _______________________

Weight: ___________________

Vision: _____________________

Hearing: _______________________

Skin: _____________________

Posture: ____________________

Socialization

Observable behaviors: _______________________________________________________________________________

Behavioral changes: ________________________________________________________________________________

Physical Appearance (e.g. personal hygiene, fatigue, attire, etc.):

Visits to Nurse

Frequency/Number:

Reasons:

___________ _______

______________________________________________________________________________

Physical Education Excuses

Number: _____________ Reasons: ________________________________________________________

Health Summary (Use additional space, if necessary):

School Nurse Signature:

Date:

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Professional School Nurse Health Form

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