Page 3 of 4 DIAGNOSTIC TESTING i.e. TB Tests, Blood Tests, X-Ray etc. Test Date Result Test Date Result Test Date Result SCOLIOSIS SCREENING Previously Date Date Date referral Date Grade pass fail Signature (Screener) pass fail Signature (Re-screener) diagnosed rescreened referred completed 6 Screened (6th grade physical may be used in place of 6th grade 6th grade physical screen) 7 VISION SCREENING Corrective Referral Annual Grade 1 Grade 1 or 2 Lenses worn Near Far Convex Date during Date Grade Signature (Screener) Date Visual Acuity Visual Acuity (Plus) Lens Vision Perception referral screening referred completed pass fail pass fail pass fail R L R L Yes No
VISION SCREENING Date Grade Annual Grade 1 Grade 1 or 2 Corrective Lenses worn during screening Referral Signature (Screener) Near Visual Acuity Far Visual Acuity Convex (Plus) Lens Vision Perception Date referred Date referral completed R L R L pass fail pass fail pass fail Yes No Page 3 of 4 DIAGNOSTIC TESTING i.e. TB Tests, Blood Tests, X-Ray etc. Test Date Result Test Date Result Test Date Result SCOLIOSIS SCREENING Date Grade pass fail Previously diagnosed Signature (Screener) Date rescreened pass fail Date referred Date referral completed Signature (Re-screener) 6 Screened 6th grade physical (6th grade physical may be used in place of 6th grade screen) 7
School%20Health%20Record.docx