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Health Assessment Record

Health Assessment Record

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 information from you which will also be helpful to the health care provider when he or she completes the medical evaluation.

Student Name(Required)

First Last

Birth Date(Required)

MM slash DD slash YYYY

Gender(Required)

Female

Male

Other

Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name(Required)

First Last

Home Phone

Cell Phone(Required)

School/Grade(Required)

Race/Ethnicity

American Indian/Alaskan Native

Hispanic/Latino

Black, not of Hispanic origin

White, not of Hispanic origin

Asian/Pacific Islander

Other

Primary Care Provider(Required)

Health Insurance Company/Number or Medicaid Number

Does your child have health insurance?(Required)

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

Yes

No

Does your child have dental insurance?(Required)

Yes

No

To be completed by parent/guardian. Please answer these health history questions about your child before the physical examination.

Any health concerns(Required)

Yes

No

If yes, please explain(Required)

Allergies to food or bee stings(Required)

Yes

No

If yes, please explain(Required)

Allergies to medication(Required)

Yes

No

If yes, please explain(Required)

Any other allergies(Required)

Yes

No

If yes, please explain(Required)

Any daily medications(Required)

Yes

No

If yes, please explain(Required)

Any problems with vision(Required)

Yes

No

If yes, please explain(Required)

Uses contacts or glasses(Required)

Yes

No

If yes, please explain(Required)

Any problems hearing(Required)

Yes

No

If yes, please explain(Required)

Any problems with speech(Required)

Yes

No

If yes, please explain(Required)

Hospitalization or Emergency Room visit(Required)

Yes

No

If yes, please explain(Required)

Any broken bones or dislocations(Required)

Yes

No

If yes, please explain(Required)

Any muscle or joint injuries(Required)

Yes

No

If yes, please explain(Required)

Any neck or back injuries(Required)

Yes

No

If yes, please explain(Required)

Problems running(Required)

Yes

No

If yes, please explain(Required)

“Mono” (past 1 year)(Required)

Yes

No

If yes, please explain(Required)

Has only 1 kidney or testicle(Required)

Yes

No

If yes, please explain(Required)

Excessive weight gain/loss(Required)

Yes

No

If yes, please explain(Required)

Dental braces, caps, or bridges(Required)

Yes

No

If yes, please explain(Required)

Concussion(Required)

Yes

No

If yes, please explain(Required)

Fainting or blacking out(Required)

Yes

No

If yes, please explain(Required)

Chest pain(Required)

Yes

No

If yes, please explain(Required)

Heart problems(Required)

Yes

No

If yes, please explain(Required)

High blood pressure(Required)

Yes

No

If yes, please explain(Required)

Bleeding more than expected(Required)

Yes

No

If yes, please explain(Required)

Problems breathing or coughing(Required)

Yes

No

If yes, please explain(Required)

Any smoking(Required)

Yes

No

If yes, please explain(Required)

Asthma treatment (past 3 years)(Required)

Yes

No

If yes, please explain(Required)

Seizure treatment (past 2 years)(Required)

Yes

No

If yes, please explain(Required)

Diabetes(Required)

Yes

No

If yes, please explain(Required)

ADHD/ADD(Required)

Yes

No

If yes, please explain(Required)

Family History

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

Yes

No

If yes, please explain(Required)

For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Any immediate family members have high cholesterol(Required)

Yes

No

If yes, please explain(Required)

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?(Required)

Yes

No

If yes, please explain(Required)

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

By signing below, I give permission for release and exchange of information on this form between the school nurse and health care provider for confidential use in meetings my child’s health and educational needs in school.

Signature of Parent/Guardian(Required)

Today's Date(Required)

MM slash DD slash YYYY

Please click SUBMIT when complete

Child and Family Agency
7 Vauxhall Street
PO Box 120
New London, CT 06320

Phone: (860) 437-4550
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