Health Assessment Record - Connecticut

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 informat ion
from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).
State law requires complete primary immunizations and a health assessment by a legally qualied practitioner of medicine, an advanced
practice registered nurse or registered nurse, a physician assistant or the school medical advisor prior to school entrance in Connecticut (C.G.S.
Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or
10th grade. Specic grade level will be determined by the local board of education. This form may also be used for health assessments required
every year for students participating on sports teams.
Part I — To be completed by parent/guardian.
Please answer these health history questions about your child before the physical examination.
Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.
Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.
Student Name (Last, First, Middle) Birth Date
Male Female
Primary Care Provider
* If applicable
Please print
To be maintained in the student’s Cumulative School Health Record
HAR-3 REV. 4/2010
Race/Ethnicity Black, not of Hispanic origin
American Indian/ White, not of Hispanic origin
Alaskan Native Asian/Pacic Islander
Hispanic/Latino Other
Health Insurance Company/Number* or Medicaid/Number*
If your child does not have health insurance, call 1-877-CT-HUSKY
Address (Street, Town and ZIP code)
Parent/Guardian Name (Last, First, Middle)
Home Phone Cell Phone
Does your child have health insurance? Y N
Does your child have dental insurance? Y N
Any health concerns Y N
Allergies to food or bee stings Y N
Allergies to medication Y N
Any other allergies Y N
Any daily medications Y N
Any problems with vision Y N
Uses contacts or glasses Y N
Any problems hearing Y N
Any problems with speech Y N
Hospitalization or Emergency Room visit Y N
Any broken bones or dislocations Y N
Any muscle or joint injuries Y N
Any neck or back injuries Y N
Problems running Y N
“Mono” (past 1 year) Y N
Has only 1 kidney or testicle Y N
Excessive weight gain/loss Y N
Dental braces, caps, or bridges Y N
Concussion Y N
Fainting or blacking out Y N
Chest pain Y N
Heart problems Y N
High blood pressure Y N
Bleeding more than expected Y N
Problems breathing or coughing Y N
Any smoking Y N
Asthma treatment (past 3 years) Y N
Seizure treatment (past 2 years) Y N
Diabetes Y N
Family History
Any relative ever have a sudden unexplained death (less than 50 years old) Y N
Any immediate family members have high cholesterol Y N
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.
I give permission for release and exchange of information on this form
between the school nurse and health care provider for condential
use in meeting my child’s health and educational needs in school.
Signature of Parent/Guardian Date
Is there anything you want to discuss with the school nurse? Y N If yes, explain:
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