Florida Form Health PDF Details

Florida Form Health is a great resource for finding health insurance in the Sunshine State. The website offers information on a variety of health plans, including Medicare and Medicaid. You can also find out how to apply for coverage and get help with your application. Florida Form Health is the best place to start if you're looking for health insurance in Florida.

If you wish to find out a handful of specific details relating to the PDF you intend to work with, here is the information you can read before completing the florida form health.

QuestionAnswer
Form NameFlorida Form Health
Form Length2 pages
Fillable?Yes
Fillable fields121
Avg. time to fill out24 min 46 sec
Other namesschool physical form florida, florida physical form 3040, dh 3040 physical form florida, 3040 form

Form Preview Example

Page 1 of 2

STATE OF FLORIDA

School Entry Health Exam

To Parent/Guardian: Please complete and sign Part I — Child’s Medical History.

State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determined by local school districts.

(Please Print)

Name of Child (Last, First, Middle)

 

Birth Date

Sex

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 about general health (eating and sleeping habits, weight, etc.)?

2.Yes No Any other specific illness or social/emotional or behavioral problems?

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, operation, or major illness (specify problem)?

7.Yes No Any significant injury or accident (specify problem)?

8.Yes No Would you like to discuss anything about 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 educational needs.

Signature of Parent/Guardian

 

Date

Partnership for School Readiness Recommendations for Prekindergarten and Kindergarten

To Parent/Guardian: Please obtain the services listed below in order to find any problems. Please 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)

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Provider:

 

 

 

 

 

 

(check one) Optometrist

Ophthalmologist

 

 

 

 

 

 

 

2. Comprehensive Dental Examination

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist:

 

 

 

 

 

 

 

 

 

 

 

 

3. Hearing Screening

 

 

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Provider:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DH3040-CHP-07/2013

Name of Child (Last, First, Middle)

School Entry Health Exam Page 2 of 2

Birth Date

PART II 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision - With Glasses

 

Right 20/_____

 

Left 20/_____

 

 

Hearing – Left

 

Passed

Failed

 

Referred

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

TB risk assessment done

(Please review Targeted Testing Guidelines listed below.)

This child has the following problems that may impact the educational experience:

Vision

Hearing

Speech/Language

Physical

Specify:

Social/Behavioral

Cognitive

This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below.

(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)

 

 

 

 

 

Tuberculosis Targeted Testing Guidelines for Health Care Providers

Tuberculosis Infection Risk:

Review the following risks and administer a Mantoux TB skin test if child is in one or more categories. The TB test is administered confidentially as part of the health examination. Do not record administration of any TB test or related information on this form.

Recent immigrant (< 5 years), frequent visitor to TB endemic areas

Close contact to active TB case

Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user

HIV+ or have other medical conditions that increase the risk to progress from infection to disease, e.g., chronic renal failure, diabetes, hematologic or any other malignancy, weight loss > 10% of ideal body weight, on immunosuppressive medications

Active TB Disease Risk:

Does the child exhibit signs/symptoms of tuberculosis (e.g. cough for three weeks or longer, weight loss, loss of appetite)?

If symptoms are present, work-up or refer for TB disease evaluation.

DH3040-CHP-07/2013

How to Edit Florida Form Health Online for Free

This PDF editor was made to be as easy as possible. While you stick to the following actions, the procedure for filling in the dh 3040 form will undoubtedly be effortless.

Step 1: Discover the button "Get Form Here" and press it.

Step 2: At the moment you're on the form editing page. You may modify and add content to the document, highlight specified content, cross or check certain words, insert images, put a signature on it, erase unwanted fields, or remove them altogether.

If you want to fill out the form, provide the information the application will require you to for each of the next sections:

filling in state of florida school entry health exam stage 1

The software will expect you to complete the Signature, of, Parent, Guardian Date, HealthCare, Provider check, one, Optometrist Ophthalmologist, Dentist, and HealthCare, Provider field.

stage 2 to finishing state of florida school entry health exam

The system will ask you for information to conveniently submit the box Name, of, Child, Last, First, Middle PART, II, MEDICAL, EVALUATION Exam, must, be, within, one, year, of, enrollment Month, Day, Year, Screening, Results Height, Weight, BMI, Passed, Failed, Referred Hc, tH, gb, Hearing, Right, Hearing, Left Lead, Urinalysis, and Passed, Passed

state of florida school entry health exam NameofChildLastFirstMiddle, PARTIIMEDICALEVALUATION, Exammustbewithinoneyearofenrollment, Month, Day, Year, ScreeningResults, Height, Weight, BMI, PassedFailedReferred, HctHgbHearingRightHearingLeft, Lead, Urinalysis, and PassedPassed fields to fill out

For field Name, Please, print, or, stamp Date, Address, Please, print, or, stamp Active, TB, Disease, Risk and DH, CHP specify the rights and responsibilities.

NamePleaseprintorstamp, Date, AddressPleaseprintorstamp, ActiveTBDiseaseRisk, and DHCHP in state of florida school entry health exam

Step 3: Hit the "Done" button. Now you may export the PDF document to your device. Besides, you may send it via email.

Step 4: Prepare a duplicate of any document. It would save you time and make it easier to remain away from complications in the future. Also, your data will not be revealed or monitored by us.

Watch Florida Form Health Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .