Fillable Printable Child & Adolescent Health Examination Form - Florida

Child & Adolescent Health Examination Form - Florida

DH 3040, 6/02 (Obsoletes previous editions which may not be used) Stock Number: 5744-000-3040-2

STATE OF FLORIDA

School Entry Health Exam

To Parent/Guardian: Please complete and sign Part I — Child’ s Medical History.

State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determined

by local school districts.

(Please Print)

Name of C hild (Las t, Firs t, Middle) Birth Date Sex

Addre s s (Street) School Grade

City and ZIP Code Home Telephone Number Par e nt/Guardian (Last, First, Middle)

PART I — CHILD’S MEDICAL HISTORY

To Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left.

(Please explain any “Yes” answers in the space provided below.)

1. Yes No Any concerns about general health ( eating and sleeping hab i ts, weight , etc.)?

2. Yes

No Any other specific illness or social/emotional or be havioral p roblems?

3. Yes

No Any allergies (food, insects, medication, etc.)?

4. Yes

No Any prescription medicatio n (daily or occasionally)?

5. Yes

No Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?

6. Yes

No Any hosp italization, operation, or major illness (specify problem)?

7. Yes

No Any significant injury or accident (specify problem)?

8. Yes

No Would you like to discuss anyt hing abo ut your child ’s health with a scho ol nurse?

To Parent/Guardian: Please explain any “Yes” answers from above.

I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this form

provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing

school hea lth services in the district f or the limited purpose of meeting my child's health and educational needs.

Signature of Parent/Guardian Date

Partnership f or School Readiness Recommendations for Prekindergarten a nd Kindergarten

To Parent/Guardian: Please obtain the services listed below in order to find any problems. Please work with your health care provider to

correct or treat any problems that may reduce your child’s ability to learn in school. (These services are recommended but not required.)

1. Comprehensive Vision Examination (3-5 years of age)

Date of Exam:

Results of Exam:

Health Care Provider:

(check one) Optometrist Ophthalmologist

Please describe an y corrective action for any problems detected

and any accommodations required.

2. Comprehensive Dental Examination

Date of Exam:

Results of Exam:

Dentist:

Please describe an y corrective action for any problems detected

and any accommodations required.

3. Hearing Screen ing

Date of Exam:

Results of Exam:

Health Care Provider:

Please describe an y corrective action for any problems detected

and any accommodations required.

Page 1 of 2

DH 3040, 6/02 (Obsoletes previous editions which may not be used) Stock Number: 5744-000-3040-2

School Entry Health Exam

Page 2 of 2

Name of C hild (Las t, Firs t, Middle) Birth Date

PART II — M EDICAL EVALUATION

To be completed and signed by the Health Care Provider ONLY:

The child named above has had a complet e history and physical exam on the f o llowing date:

(Exam must be within one year of enrollment)

Month Day Year

Screening Results:

Height: Weight: BMI%: B/P: Hct/Hgb: Lead: Urinalysis:

Vision - Without Glasses

Right 20/_____ Left 20/_____

Hearing – Righ t P a ssed Failed Referred

Vision - With Glasses

Right 20/_____ Left 20/_____

Passed

Failed

Referred

Hearing – Left Passed Failed Referred

Gross dental (teeth and gums) Normal Abnormal Refer/Tx:

Head/scalp/skin

Normal Abnormal Refer/Tx:

Eyes/Ears/Nose/Throat Normal Abnormal Refer/Tx:

Chest/Lungs/Heart Normal Abnormal Refer/Tx:

Abdomen Normal Abnormal Refer/Tx:

P ostural assessment Normal Abnormal Refer/Tx:

TB risk assessment done

(Please review Targeted Testing Guidelines listed below.)

This ch i ld has the foll owing problems that may impact the educational experience:

Vision Hearing S peech/Language P hysical Social/Behavi oral Cognitive

Specif y:

This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below.

(This form will be stored in the child’s Cumulative Health Folder and may be accessed by bo th school and health personnel.)

Recommendat ions (Attach ad dition al sheet if necessary):

(Please Check One)

This ch ild may participate fully in school activities including physical education.

This ch ild may participate in school activities including physical education with the following restriction/adaptation.

(Specify reason and restriction)

Signature/Title of Health Care Provider Date Address (Please print or stamp)

___/___/___

Name (Please print or stamp)

Tuberculosis Targeted Testing Guidelines for Health Care Providers

Tuberculos is Infection Ri sk:

Review the following risks and administer a Mantoux TB skin test if child is in one or more categories. The TB test is administered confidentially

as part of the health examination. Do not record administration of any TB test or related information on this form.

· Recent immigrant (< 5 years), frequent visitor to TB endemic areas

· Close contact to active TB case

· Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user

· HIV+ or have other medical conditions that increase the ris k to progress from infection to disease, e.g., chronic renal failure,

diabetes, hematol ogic or any other ma lignancy, wei ght loss > 10 % of idea l body weight, on immunosuppressive medica tions

Act ive TB Di sease Ri sk:

· Does t he child exhibit signs /symptoms of tuber culosis (e.g. cough f or three weeks or longer, wei ght loss, los s of appetite)?

· If symptoms are present, work-up or refer for TB disease evaluation.