1. COMPREHENSIVE EVALUATION HEALTH ASSESSMENT
      1. Student’s Name: ______________________D.O.B. _____________ Grade: ________
      2. 2. Observations:
      3. 3. How often does the student come to the health room/nurse office?
      4. 6. Summary and conclusions for the Team to consider:
      5. Summary of health history known to the school:
      6. Conclusions:


 
COMPREHENSIVE EVALUATION HEALTH ASSESSMENT



Student’s Name: ______________________D.O.B. _____________ Grade: ________
 

1. Vision: _________________ Glasses/Contacts: _______ Hearing: _________________

          Date Results Yes/No Date Results
 


2. Observations:
 
a. Multiple Choice (Mark all areas of concern-suspected or otherwise)

__ i. Hygiene_______________________________________________
 
__ ii. Substance/alcohol abuse__________________________________
 
__ iii. Nutrition_______________________________________________
 
__ iv. Headaches_____________________________________________
 
__ v. Stomachaches__________________________________________
 
__ vi. Fatigue________________________________________________
 

 
__ vii. Irritability_______________________________________________

__ viii. Other__________________________________________________
 


3. How often does the student come to the health room/nurse office?

Rarely, Daily, Weekly, Monthly (Circle one) What is the reason for the visit?______________
__________________________________________________________________________

4. Does the student have a medical/mental health diagnosis? (check) _____ Yes ______ No

If yes, diagnosis? ____________________________________________________________

5. Does the student take medication? (Check) ______Yes ______ No _____ I don’t know

Last parent contact: ____________________________________________
Yes: Medication Name and amount: ________________________________
__________________________________________________________________________
Does the student take the medication at home or school? (circle one or both)


6. Summary and conclusions for the Team to consider:



Summary of health history known to the school:
 
 


 
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

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