Health Information Form printable pdf download

HEALTH INFORMATION (Required prior to Tier I Meeting)

Parent Contact

____________________________________

_________________________________________

_____________

Student/ID #

Referring Staff Member/Position

Date

NOTE: NURSE HAS 5 WORKING DAYS TO COMPLETE FORM

INTERVIEWER: _____________________________________RN:________LVN:_______DATE RECEIVED: _____________________

HEALTH SCREENING

Student: ___________________________ DOB: ______

HT. _______WT.________FOC_______B/P________BMI______

%______ %______ %_____ %______ %_____

STUDENT’S GENERAL HEALTH & MEDICAL HISTORY

Briefly describe any serious illnesses, accidents or hospitalization.

VISION & HEARING

_____________________________________________________________

Distance Visual Acuity: ________________________

_____________________________________________________________

Results without glasses: right 20/_____left 20/______

_____________________________________________________________

Results with glasses: right 20/_______left 20/_______

______________________________________________________________

Results: ________Pass ________Fail /Date: ________

______________________________________________________________

Near Visual Acuity: ___________________________

Does the child have physical or health problems? __Yes __ No If Yes,

Results: ______Pass ______Fail/Date: ____________

please explain: __________________________________________________

Type of hearing screening: ___Sweep audiometry

______________________________________________________________

___Threshold audiometry ___Other ______________

Is your child under the care of a physician? __ Yes __ No If Yes, please

___________________________________________

Results: __ Pass __ Fail/Date: ___________________

explain: _______________________________________________________

Person conducting Screening(s):_________________

______________________________________________________________

Position: ____________________________________

______________________________________________________________

HISTORY OF PREGNANCY

Is your child taking any medicines? ___ Yes ___ No If Yes, please

Age of mother at birth of student: ______________

explain: _______________________________________________________

Presence of the following during pregnancy:

1. Bleeding ____ Yes ____ No

Has your child ever taken medicine for a long period of time? ___Yes___No

If Yes, please explain: ____________________________________________

2. X-rays ____ Yes ____ No

3. Illness ____ Yes ____ No

_______________________________________________________________

Specify: __________________________________

4. Medications ____ Yes ____ No

Does your child appear to have any side effects from the medicine? ___Yes

If Yes, please explain: ____________________________________________

5. Diabetes ____ Yes ____ No

6. Accidents ____ Yes ____ No

______________________________________________________________

7. Surgery ____ Yes ____ No __ No

______________________________________________________________

Full Term _____________ Premature __________

______________________________________________________________

Birth weight: ___________

Were there any problems before, during, or immediately

Does your child use any special equipment or technology? __ Yes __No If

Yes, please explain: ______________________________________________

After birth? __Yes ___No

Is your child receiving services from another agency? __Yes __No If Yes,

please explain: __________________________________________________

STUDENT’S DEVELOPMENTAL HISTORY

FURTHER ASSESSMENT

Sat at ___ months Walked at ___ months

As a result of health screening, is there indication of a need for further

assessment of vision, hearing or general health? ___Yes ___No If Yes,

Talked at ___ months

please explain problem/concern:

Comparisons with brothers, sisters, or other children

______________________________________________________________

at about the same age:

______________________________________________________________

_____ About the same _____ Slower ____ Faster

______________________________________________________________

Does anyone in the family have conditions similar

______________________________________________________________

to those of the student? ____ Yes ____ No

______________________________________________________________

Is there a history in the family of:

______________________________________________________________

Learning or reading disorder: ___Yes ___No

______________________________________________________________

Note: Referral to a health care provider must be accompanied by results of

Mental retardation: ___Yes ___No

Emotional illness: ___ Yes ___ No

screening tests.

Signature: _______________________________ Title: _______________________ Date Completed: ____________________________

SAISD C&I Department-RtI 6-Secondary

9 of 12

REVISED: 09/2009

Health Information Form

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