Keeping track of student health records is an important part of maintaining the well-being and safety of a school. Having accurate and up-to-date information on hand can help prevent any medical emergency that may arise in the future. A School Health Record Form can make this possible by providing parents, teachers, and administrators with all necessary data pertaining to a student’s health status. This blog post will discuss how to create such a form from start to finish, including best practices for gathering required information from parents and known allergies or other conditions that should be added in the form. With our tips in mind, you'll have your school's health record form ready for use with minimal effort!
| Question | Answer |
|---|---|
| Form Name | School Health Record Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ma health examination, massachusetts school health form, health provider examination, massachusetts school health |
MASSACHUSETTS SCHOOL HEALTH RECORD
HEALTH CARE PROVIDER’S EXAMINATION
Name ________________________________________ |
Male |
Female Date of Birth:___________________ |
Medical History _________________________________________________________________________________________
_______________________________________________________________________________________________________
Pertinent Family History
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Current Health Issues |
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N |
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Allergies: Please list: Medications ______________________ Food _________________ Other ______________ |
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History of Anaphylaxis to ___________________ Epi |
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Yes |
No |
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Asthma: |
Asthma Action Plan |
Yes |
No (Please attach) |
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Diabetes: |
Type I |
Type II |
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Seizure disorder: ____________________________________________________________________________ |
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Other (Please specify) _________________________________________________________________________ |
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Current Medications (if relevant to the student's health and safety) |
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Please circle those administered in school; a separate |
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medication order form is needed for each medication administered in school. |
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Physical Examination |
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Date of Examination:___________________________ |
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Hgt: ________(_____%) Wgt:_________(_____%) BMI: _________(_____%) BP: ________ |
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(Check = Normal / If abnormal, please des cribe.) |
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General ________________ |
Lungs __________________ |
Extremities _____________ |
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Skin __________________ |
Heart ___________________ |
Neurologic _____________ |
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HEENT _______________ |
Abdomen _______________ |
Other __________________ |
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Dental/Oral ____________ |
Genitalia ________________ |
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Screening: |
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(Pass) (Fail) |
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(Pass) (Fail) |
(Pass) (Fail) |
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Vision: Right Eye |
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Hearing: Right Ear |
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Postural Screening: |
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Left Eye |
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Left Ear |
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(Scoliosis/Kyphosis/Lordosis) |
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Stereopsis |
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Laboratory Results: |
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Lead _______ Date _______________ |
Other____________________________________ |
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The entire examination was normal : |
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Targeted TB Skin Testing : |
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TB Test Type: |
TST |
IGRA Date: ____________ Result: |
Positive Negative Indeterminate/Borderline |
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Referred for evaluation to: |
_________________________________________ Date:_______ |
Low risk (no TB test done) |
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This student has the following problems that may impact his/her educational experience:
Vision |
Hearing |
Speech/Language |
Emotional/Social |
Behavior |
Other |
Fine/Gross Motor Deficit
Comments/Recommendations :_____________________________________________________________________
Y |
N This student may participa te fully in the school program, including physical education and competitive sports. If |
no, please list restrictions: _____________________________________________________________________________________
Y |
N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System |
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Certificate or other complete immunization record . |
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______________________________________________ |
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Signature of Examiner |
Circle: MD, DO, NP, PA Date |
Please print name of Examiner. |
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Group Practice |
Telephone |
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Address |
City |
State |
Zip Code |
Please attach additional information as needed for the health and safety of the student. |
MDPH 08/15/13 |