The Maryland School for the Blind PART II SCHOOL HEALTH ASSESSMENT – Health Center - School Year 2017-2018 To be completed ONLY by Practitioner Student’s Name (Last, First, Middle) Birthdate (Mo. Day Yr.) Sex M F Does the child have a diagnosed medication condition? No Yes Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school? (e.g. seizure, insect sting allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) if yes, please DESCRIBE. Additionally, please with your school nurse to develop an emergency plan.” “work No Yes Evaluation Findings/CONCERNS Physical Exam WNL ABNL COMMENTS Health Area of Concern YES NO Head Attention Deficit/Hyperactivity Eyes Behavior/Adjustment ENT Development Dental Hearing Respiratory Immunodeficiency Cardiac Lead Exposure/Elevated Lead GI Learning Disabilities/Problems GU Mobility Musculoskeletal/Orthopedic Nutrition Neurological Physical Illness/Impairment Skin Psychosocial Endocrine Speech/Language Psychosocial Vision Other REMARKS: (Please explain any abnormal findings.) Screenings Results Date Taken Tuberculin Test Blood Pressure Height Weight BMI % tile Lead Test Optional Medical evaluation of students for participation in interscholastic athletics. May this student participate in the supervised activities listed? Yes No Comments Wrestling Swimming Goalball Cheerleading Track Contact Sports Yes No Comments Risk of Retinal Detachment Long Duration of Intense Cardiovascular Activity Any Weight Bearing Restrictions: i.e., Lifting Weights Special Requirements for Sun Exposure Tumbling Activities Must Wear Eye Protection During Physical Activity Student has had a complete history and physical examination at our office and has no evident health problem except as noted above.
The Maryland School for the Blind PART II – SCHOOL HEALTH ASSESSMENT Health Center - School Year 2017-2018 To be completed ONLY by Practitioner Student’s Name (Last, First, Middle) Birthdate (Mo. Day Yr.) Sex M F Does the child have a diagnosed medication condition? No Yes Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school? (e.g. seizure, insect sting allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) if yes, please DESCRIBE. Additionally, please “work with your school nurse to develop an emergency plan.” No Yes Evaluation Findings/CONCERNS Physical Exam WNL ABNL COMMENTS Health Area of Concern YES NO Head Attention Deficit/Hyperactivity Eyes Behavior/Adjustment ENT Development Dental Hearing Respiratory Immunodeficiency Cardiac Lead Exposure/Elevated Lead GI Learning Disabilities/Problems GU Mobility Musculoskeletal/Orthopedic Nutrition Neurological Physical Illness/Impairment Skin Psychosocial Endocrine Speech/Language Psychosocial Vision Other REMARKS: (Please explain any abnormal findings.) Screenings Results Date Taken Tuberculin Test Blood Pressure Height Weight BMI % tile Lead Test Optional Medical evaluation of students for participation in interscholastic athletics. May this student participate in the supervised activities listed? Yes No Comments Wrestling Swimming Goalball Cheerleading Track Contact Sports Yes No Comments Risk of Retinal Detachment Long Duration of Intense Cardiovascular Activity Any Weight Bearing Restrictions: i.e., Lifting Weights Special Requirements for Sun Exposure Tumbling Activities Must Wear Eye Protection During Physical Activity Student has had a complete history and physical examination at our office and has no evident health problem except as noted above.
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