Form Har-3 - Health Assessment Record - State Of Connecticut Department Of Education Page 2
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1
2HAR-3
Part II — Medical Evaluation
REV. 4/2012
Health Care Provider must complete and sign the medical evaluation and physical examination
Student Name
Birth Date
Date of Exam
I have reviewed the health history information provided in Part I of this form
❑
Physical Exam
Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law
*Weight _____ lbs. / _____% BMI _____ / _____% Pulse _____ *Blood Pressure _____ / _____
*Height _____ in. / _____%
Normal
Describe Abnormal
Ortho
Normal
Describe Abnormal
Neurologic
Neck
HEENT
Shoulders
*Gross Dental
Arms/Hands
Lymphatic
Hips
Heart
Knees
Lungs
Feet/Ankles
Abdomen
*Postural
No spinal
Spine abnormality:
❑
❑
Genitalia/ hernia
abnormality
Mild
Moderate
❑
❑
Marked
Referral made
❑
❑
Skin
Screenings
Date
*Vision Screening
*Auditory Screening
History of Lead level
µ
≥ 5
g/dL ❑ No ❑ Yes
Type:
Right
Left
Type:
Right
Left
Pass
Pass
*HCT/HGB:
With glasses
20/
20/
❑
❑
Fail
Fail
❑
❑
Without glasses
20/
20/
*Speech
(school entry only)
Referral made
Referral made
Other:
❑
❑
TB: High-risk group?
No
Yes
PPD date read:
Results:
Treatment:
❑
❑
*
IMMUNIZATIONS
Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED
Up to Date or
❑
❑
*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.
Signature of health care provider
Date Signed
Printed/Stamped Provider Name and Phone Number
MD / DO / APRN / PA
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