Screening Form - Florida Department Of Health (Page 2 of 4) in pdf

Screening Form - Florida Department Of Health Page 2

LEVEL I SCREENING

The next questions are about any kind of health problems, concerns, or conditions that may affect your child’s

physical health, behavior, learning, growth, or physical development. Some of these health problems may affect

your child’s abilities and activities at school or play. Some of these problems affect the kind or amount of services

your child may need or use.

1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)?

________ Yes – Go to Question 1a

________ No – Go to Question 2

1a. Is this because of ANY medical, behavioral, or other health condition?

________ Yes – Go to Question 1b

________ No – Go to Question 2

1b. Is this a condition that has lasted or is expected to last for at least 12 months?

________ Yes

________ No

1c. What is the condition or diagnosis? ______________________________________________

2. Does your child need or use more medical care, mental health, or education services than is usual for

most children of the same age?

________ Yes – Go to Question 2a

________ No – Go to Question 3

2a. Is this because of ANY medical, behavioral, or other health condition?

________ Yes – Go to Question 2b

________ No – Go to Question 3

2b. Is this a condition that has lasted or is expected to last for at least 12 months?

________ Yes

________ No

2c. What is the condition or diagnosis? ______________________________________________

3. Is your child limited or prevented in any way in his or her ability to do the things most children of the

same age can do?

________ Yes – Go to Question 3a

________ No – Go to Question 4

3a. Is this because of ANY medical, behavioral, or other health condition?

________ Yes – Go to Question 3b

________ No – Go to Question 4

3b. Is this a condition that has lasted or is expected to last for at least 12 months?

________ Yes

________ No

3c. What is the condition or diagnosis? ______________________________________________

Form DH8000 (12/2015)

Rule 64C-2.002, Florida Administrative Code

Screening Form - Florida Department Of Health Page 2