Child & Adolescent Health Examination Form - Florida

DH 3040, 6/02 (Obsolet es previous editi ons which m ay not be us ed) St oc k Number: 5744-000-3040-2
STATE OF FLORIDA
School Entry Health Exam
To Parent/Guardian: Please co mplete and sign Part I — Ch ild’s Medical History.
State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be d etermined
by local school districts.
(Please Print)
Name of C hild (Las t, First, Middle) Bir th Date Sex
Addre ss (Stre e t) School Grade
City and ZIP C ode Home Tele phone Number Par e nt/Guardian (L a s t, First, Mi ddle )
PART I CHILD’S M E DICAL 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 co ncerns abo ut general health (e ating and slee ping habits, weight, etc .)?
2. Yes
No Any other specific illness or social/emotional or be havioral p roblems?
3. Yes
No Any allergies (food, insects, medication, etc.)?
4. Yes
No Any prescription medication (daily or occasionally)?
5. Yes
No Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?
6. Yes
No Any hospitalization, op eration, o r major illness (specify problem)?
7. Yes
No Any significant injury or accident (specify problem)?
8. Yes
No Wo ul d you like to discuss anyt hi ng abo ut your child’s health with a school nurse?
To Parent/Guardian: Please explain any “Yes” answers from above.
I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this form
provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing
school health services in the district for the limited purpose of meeting my child's health and educatio na l needs.
Ö
Signature of Parent/Guardian Date
Part nership for School Rea diness Recommenda tions for Prekindergarten and Kindergarten
To P arent/Guardian: Please obtain the services listed below in order to find any problems. P lease work with your health care provider to
correct or treat any problems that may reduce your child’s ability to learn in school. (These services are recommended but not required.)
1. Comprehensive Vision Examination (3-5 years of age)
Date of Exam:
Results of Exam:
Health Care Provider:
(check o ne) Optometrist Ophthalmologist
Please describe any corrective actio n for any pro blems detected
and any acco mmodation s required .
2. Comprehensive Dental Examination
Date of Exam:
Results of Exam:
Dentist:
Please describe any corrective actio n for any pro blems detected
and any acco mmodation s required .
3. Hearing Screen ing
Date of Exam:
Results of Exam:
Health Care Provider:
Please describe any corrective actio n for any pro blems detected
and any acco mmodation s required .
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