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COMPREHENSIVE EVALUATION HEALTH ASSESSMENT
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1. | Vision: _________________ Glasses/Contacts: _______ Hearing: _________________ |
2. | Observations: |
a. | Multiple Choice (Mark all areas of concern-suspected or otherwise) | |
__ vii. Irritability_______________________________________________ | |
3. | How often does the student come to the health room/nurse office? |
4. | Does the student have a medical/mental health diagnosis? (check) _____ Yes ______ No |
5. | Does the student take medication? (Check) ______Yes ______ No _____ I don’t know |
6. | Summary and conclusions for the Team to consider: |
Conclusions: | |
___a) The student has a health condition that appears to impact his/her educational performance | |
___b) The student has a health condition that does not appear to impact his/her educational performance. | |
___c) The student does not have a documented health condition. | |
___d) Other ___________________________________________________________________________ | |
____________________________________ _________________ ____________________________ | |
Nurse’s Signature Date School |