Fillable Printable Health Assessment Record - Connecticut

Health Assessment Record - Connecticut

State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests informat ion

from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assessment by a legally qualied practitioner of medicine, an advanced

practice registered nurse or registered nurse, a physician assistant or the school medical advisor prior to school entrance in Connecticut (C.G.S.

Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or

10th grade. Specic grade level will be determined by the local board of education. This form may also be used for health assessments required

every year for students participating on sports teams.

Part I — To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.

Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Student Name (Last, First, Middle) Birth Date

❑ Male ❑ Female

Primary Care Provider

* If applicable

Please print

To be maintained in the student’s Cumulative School Health Record

HAR-3 REV. 4/2010

Race/Ethnicity ❑ Black, not of Hispanic origin

❑ American Indian/ ❑ White, not of Hispanic origin

Alaskan Native ❑ Asian/Pacic Islander

❑ Hispanic/Latino ❑ Other

School/Grade

Health Insurance Company/Number* or Medicaid/Number*

If your child does not have health insurance, call 1-877-CT-HUSKY

Address (Street, Town and ZIP code)

Parent/Guardian Name (Last, First, Middle)

Home Phone Cell Phone

Does your child have health insurance? Y N

Does your child have dental insurance? Y N

Any health concerns Y N

Allergies to food or bee stings Y N

Allergies to medication Y N

Any other allergies Y N

Any daily medications Y N

Any problems with vision Y N

Uses contacts or glasses Y N

Any problems hearing Y N

Any problems with speech Y N

Hospitalization or Emergency Room visit Y N

Any broken bones or dislocations Y N

Any muscle or joint injuries Y N

Any neck or back injuries Y N

Problems running Y N

“Mono” (past 1 year) Y N

Has only 1 kidney or testicle Y N

Excessive weight gain/loss Y N

Dental braces, caps, or bridges Y N

Concussion Y N

Fainting or blacking out Y N

Chest pain Y N

Heart problems Y N

High blood pressure Y N

Bleeding more than expected Y N

Problems breathing or coughing Y N

Any smoking Y N

Asthma treatment (past 3 years) Y N

Seizure treatment (past 2 years) Y N

Diabetes Y N

ADHD/ADD Y N

Family History

Any relative ever have a sudden unexplained death (less than 50 years old) Y N

Any immediate family members have high cholesterol Y N

Please list any medications your

child will need to take in school:

All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.

I give permission for release and exchange of information on this form

between the school nurse and health care provider for condential

use in meeting my child’s health and educational needs in school.

Signature of Parent/Guardian Date

Is there anything you want to discuss with the school nurse? Y N If yes, explain:

Part II — Medical Evaluation

Health Care Provider must complete and sign the medical evaluation and physical examination

HAR-3 REV. 4/2010

Signature of health care provider Date Signed Printed/Stamped Provider Name and Phone Number

Physical Exam

Birth DateStudent Name Date of Exam

❑

I have reviewed the health history information provided in Part I of this form

Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law

*Height _____ in. / _____% *Weight _____ lbs. / _____% BMI _____ / _____% Pulse _____ *Blood Pressure _____ / _____

Screenings

Neurologic

HEENT

*Gross Dental

Lymphatic

Heart

Lungs

Abdomen

Genitalia/ hernia

Skin

Neck

Shoulders

Arms/Hands

Hips

Knees

Feet/Ankles

Describe AbnormalNormal NormalOrtho Describe Abnormal

*Postural ❑ No spinal ❑ Spine abnormality:

abnormality ❑ Mild ❑ Moderate

❑ Marked ❑ Referral made

*Vision Screening

With glasses

20/

Right Left

20/

Without glasses

20/ 20/

❑ Referral made

Type:

*Auditory Screening

Right Left

❑ Referral made

Type:

❑ Pass ❑ Pass

❑ Fail ❑ Fail

*HCT/HGB:

Lead:

Other:

Date

TB: High-risk group? ❑ No ❑ Yes PPD date read: Results: Treatment:

*IMMUNIZATIONS

❑ Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

Asthma ❑ No ❑ Yes: ❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced

If yes, please provide a copy of the Asthma Action Plan to School

Anaphylaxis ❑ No ❑ Yes: ❑ Food ❑ Insects ❑ Latex ❑ Unknown source

Allergies If yes, please provide a copy of the Emergency Allergy Plan to School

History of Anaphylaxis ❑ No ❑ Yes Epi Pen required ❑ No ❑ Yes

Diabetes ❑ No ❑ Yes: ❑ Type I ❑ Type II Other Chronic Disease:

Seizures ❑ No ❑ Yes, type:

❑ This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience.

Explain: ____________________________________________________________________________________________________

Daily Medications (specify): ____________________________________________________________________________________

This student may: ❑ participate fully in the school program

❑ participate in the school program with the following restriction/adaptation: _____________________________

___________________________________________________________________________________________________________

This student may: ❑ participate fully in athletic activities and competitive sports

❑ participate in athletic activities and competitive sports with the following restriction/adaptation: ____________

___________________________________________________________________________________________________________

❑ Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.

Is this the student’s medical home? ❑ Yes ❑ No ❑ I would like to discuss information in this report with the school nurse.

MD / DO / APRN / PA

Immunization Record

To the Health Care Provider: Please complete and initial below.

Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only.

DTP/DTaP

DT/Td

Tdap

IPV/OPV

MMR

Measles

Mumps

Rubella

HIB

Hep A

Hep B

Varicella

PCV

Meningococcal

HPV

Flu

Other

Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

Students under age 5

Pneumococcal conjugate vaccine

Disease Hx ________________________________ ________________________________ ________________________________

of above (Specify) (Date) (Conrmed by)

Immunization Requirements for Newly Enrolled Students at Connecticut Schools

KINDERGARTEN DTaP: At least 4 doses. The last dose must be given on or after 4th birthday

Polio: At least 3 doses. The last dose must be given on or after 4th birthday

MMR: 1 dose on or after the 1st birthday

Measles: Second dose of measles vaccine (or MMR), given at least 4 weeks after the rst dose

Hib: Children less than 5 yrs of age need 1 dose at 12 months or older Children 5 and older do not need proof of Hib vaccination

Hep B: 3 doses

Varicella: 1 dose on or after the 1st birthday or verication of disease

GRADES 1-6 DTaP /Td/Tdap: At least 4 doses. The last dose must be given on or after 4th birthday

Students who start the series at age 7 or older only need a total of 3 doses

Polio: At least 3 doses. The last dose must be given on or after 4th birthday

MMR: 1 dose on or after the 1st birthday

Measles: Second dose of measles vaccine (or MMR), given at least 4 weeks after the rst dose

Hep B: 3 doses

Varicella: 1 dose on or after the 1st birthday or verication of disease

GRADES 7-12 Td/Tdap: At least 3 doses. The last dose must be given on or after 4th birthday. Students who start the series at age 7 or older

only need a total of 3 doses

Polio: At least 3 doses. The last dose must be given on or after 4th birthday

MMR: 1 dose on or after the 1st birthday

Measles: Second dose of measles vaccine (or MMR), given at least 4 weeks after the rst dose

Hep B: 3 doses

Varicella: 1 dose on or after rst birthday or verication of disease:

VARICELLA VACCINE: For students <13 years of age, 1 dose given on or after the 1st birthday. For students 13 years of

age or older, 2 doses given at least 4 weeks apart

VERIFICATION OF DISEASE: Conrmation in writing by a MD, PA, or APRN that the child has a previous history of

disease, based on family or medical history

Exemption

Religious _____ Medical: Permanent _____ Temporary _____ Date _____

Recertify Date _________ Recertify Date _________ Recertify Date ________

Initial/Signature of health care provider Date Signed Printed/Stamped Provider Name and Phone Number

MD / DO / APRN / PA

HAR-3 REV. 4/2010