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State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

cian assistant, licensed pursuant to chapter 370, a school medical advisor, or

In order to provide the best educational experience, school personnel

a legally qualified practitioner of medicine, an advanced practice registered

must understand your child’s health needs. This form requests information

nurse or a physician assistant stationed at any military base prior to school

from you (Part I) which will also be helpful to the health care provider when

entrance in Connecticut (C.G.S. Secs. 10-204a and 10-206). An immunization

he or she completes the medical evaluation (Part II).

update and additional health assessments are required in the 6th or 7th grade

State law requires complete primary immunizations and a health assess-

and in the 9th or 10th grade. Specific grade level will be determined by the

ment by a legally qualified practitioner of medicine, an advanced practice

local board of education. This form may also be used for health assessments

registered nurse or registered nurse, licensed pursuant to chapter 378, a physi-

required every year for students participating on sports teams.

Please print

Student Name

Birth Date

Male

Female

(Last, First, Middle)

❑

Address

(Street, Town and ZIP code)

Home Phone

Cell Phone

Parent/Guardian Name

(Last, First, Middle)

School/Grade

Race/Ethnicity

Black, not of Hispanic origin

❑

American Indian/

White, not of Hispanic origin

❑

Alaskan Native

Asian/Pacific Islander

❑

Primary Care Provider

Hispanic/Latino

Other

❑

Health Insurance Company/Number* or Medicaid/Number*

Does your child have health insurance?

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

Does your child have dental insurance?

* If applicable

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.

Any health concerns

Concussion

Hospitalization or Emergency Room visit

Allergies to food or bee stings

Any broken bones or dislocations

Fainting or blacking out

Allergies to medication

Any muscle or joint injuries

Chest pain

Any other allergies

Any neck or back injuries

Heart problems

Any daily medications

Problems running

High blood pressure

Any problems with vision

“Mono” (past 1 year)

Bleeding more than expected

Uses contacts or glasses

Has only 1 kidney or testicle

Problems breathing or coughing

Any problems hearing

Excessive weight gain/loss

Any smoking

Any problems with speech

Dental braces, caps, or bridges

Asthma treatment (past 3 years)

Seizure treatment (past 2 years)

Family History

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

Diabetes

Any immediate family members have high cholesterol

ADHD/ADD

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

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

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 confidential

Signature of Parent/Guardian

Date

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

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

HAR-3

REV. 4/2012

Form Har-3 - Health Assessment Record - State Of Connecticut Department Of Education

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