Aparri School of Arts and Trades

School Entry Health Exam

To parent/ Guardian: Please complete and sign Part I- Child’s Medical History
Name of Child (Last, First, Middle) Birth Date: Sex:

Home Address (Street) School: Grade:

City and ZIP Code Home Telephone Number Parent/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
P about general health (eating and sleeping habits, weight, etc.)?
P
2. Yes P No Any other
PA specific illness or social/emotional or behavioral problems?
A
3. Yes PA No Any allergies
PR (food, insects, medication, etc.)?
R A
4. Yes PA No Any prescription medication (daily or occasionally)?
R PRAT
5. Yes P AR No TAny problems with vision, hearing, or speech(glasses,contacts, ear tubes, hearing aids)?
T PI A R
TI
6. Yes P A R No Any hospitalization, operation, or major illness (specify problem)?
TI P A— RIT—
7. Yes A P
R No Any significant injury or accident (specify problem)?
TI— A P
RC T—ICyou like to discuss anything about your child’s health with a school nurse?
8. Yes PR A No Would
TI— C R TPH
A IC—H
ATRI— CH R
TI I A — CI
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To Parent/Guardian: L IHL
Please explain any “Yes” answers from above.
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________________________________________ O ____________________________
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 Aparri School of Arts and Trades
School Entry Health Exam

Name of Child (Last, First, Middle) Birth Date: Sex:

Home Address (Street) School: Grade:

City and ZIP Code Home Telephone Number Parent/Guardian (Last, First, Middle)

MEDICAL EVALUATION
To be completed and signed by the Health Care Provider ONLY:
The child named above has had a complete history and physical exam on the following 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/___ Passed Hearing – Right Passed Failed Referred
Failed e
Vision - With Glasses Right 20/___ Left 20/___ 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: ___________
Postural assessment Normal Abnormal ____________ Refer/Tx: ___________

This child has the following problems that may impact the educational experience:
Vision Hearing Speech/Language Physical Social/Behavioral Cognitive

Specify:______________________________________________________________________________
_____________________________________________________________________________________

This child has a health condition that may require emergency action at school, e.g. seizures, allergies.
Specify: _________________________________________________________________________
(This form will be stored in the child’s Cumulative Health Folder and may be accessed by both school
and health personnel.)

Recommendations (Attach additional sheet if necessary)_______________________________________

____________________________________________________________________________________

(Please Check One)

This child may participate fully in school activities including physical education.
This child 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)