EFTA01710352.pdf

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HEALTH EXAMINATION He lit Blood Pre-sure (I) Normal-It Abnormal =A N ty COMMENT: Abnormal Findings, by number ( 1. Appearance 2. Skin/Nose 2 Head/Scalo 4 Eyes E. Visual Acuity IR 8 L) E Ears i Auditory Acuity IR 8 LI E Nose / Throat 9. Mouth. Teeth and Gums 10. Clital / Lungs 11 Heart 12. Abdomen 13. Borstals and Anus 14 Musculo-Skeletal 15. NetstilOgiCal 16 Alertness 17. Emotional Mental/ Behavior Rub) 18 Handicap. physical/ other (Speedy) 19. Activity Restrictions ISPecifyl 20. Abuse. substance/ physical / emotional 21. Nutrition 22 Other B. HEALTH HISTORY tsercvs I blesses triunes: exerainl /1/ (attach narrative if additional space needed) C. LABORATORY (as indicated) HemoglebintHematoent Stool 10 & -uberculin te8 Load Sickle Cell NAME: ADDRESS: (Please Print) Authorized Signature ate DM 3040. 1046 (Rap-aces HRS-H Form 3010 wh c.h may be us•O) (Sto4.4 N4mOar. 5744.003.3040-2) EFTA01710353  NARRATIVE RECORD Notations by educators, nurses and other designated personnel should be dated and signed. Narration section should include information concerning referrals, follow-up and special consideration to be given students in classroom as a result of screening, as well as teachers' observations, parent conferences, home visitations and services rendered. Educators need only record information concerning teacher observation and educational decisions made for stucents in the classroom as a result of screening and other health information. DATE aitLacai Ail14/_, ‘---Le attic_ c HRS-H Form 3041, MAY 80 (3) EFTA01710354  STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES Special Health CUMULATIVE SCHOOL HEALTH RECORD Problems - See (This form is not intended for physician's use) Narrative Name _ Race L) Sex F School Address, Father's Name Mother's Name Date of Birth Place of Birth CO (Sri- ?Dial BPGehr Fl Birth Recorded: Yes El— No O Immunization Certification: Yes Ear No O Special Immunization Prcgrams A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES K 1 2 3 Screening and Screening Screening sio=utcome Outcome Outcome Outcome Assessment 13. aC 16 a) C 7.! Date •E a) .. i Date Grades *E m ii, CD A ZS 8 8 K-3 0 ft CD O CD ? 8 G so cc 33 cc 8 Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Other Other 4 5 6 7 8 Screening and ci, ci) ai ci, Screening 4. Outcome Outcome Outcome Outcome Assessment c o Ts c To C TO 'E CD - 13' Date Grades t C 0 •-• t •E a) t '2 m 't in 0 0 to 0 e to 0 0 to 0 ZI:, g o 4-8 eo 0 II Es 0 o 1S I' 0 o 115 e. 0 15 • 5 cc CC cc m , CC CC 0 I I cn co cn i Vision Hearing Height, Weight & Graphing .., Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Scoliosis Other _ . Other _._ , EFTA01710355  • atuan Lae e, % , each,jr 3"`t- r hipzienrlifie ,avaderenview AgjAri.XaytelaZ atria Aiapi %%BanosBlurtofAgrAWAV aledetatafeilelata4 Atredhteied Awid ' , re/meads EFTA01710356  V., 09 FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) flutida Statutes 232.032) OF MALIII PAO FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE 0.1 RATE OF R'RTH CHILD'S NAME MO DA YR PARENT OR GUARDIAN DETOP: PART A OF THIS FORM IS USED ONLY IF THE CHILD HAS MERE() ALL REQUIRED INMUNIZATIOAS LISTED BELOW. IF NOT. SEE REVERSE SIDE. CTP - 5 DOSES REQUIRED • IF THE FOURTH PR MARY DOSE OF CTP IS ADMINISTERED ON OR AFTER THE FOURTH BIRTHDAY, A FIFTH DOSE IS NOT REQUIRED. CT (PEDIATRIC) VACCINE IS ACCEPTABLE IF PERTUSSIS VACCINE IS MEDICALLY CENTRAINDICATEO (COMPLETE PART C FOR PERTUSSIS CONTRAINDICATION.) ii (ADULT) VACCINE (A SERIES OF 3 DOSES) IS ACCEPTABLE AND RECOMMENDED FOR CHILDREN 7 YEARS OF AGE OR OLDER. POLIO (TCPV) - 4 DOSES REQUIRED MO DA YR MO DA YR MO OA YR MO DA YR IF THE THIRD ETIIMARY DOSE OF TO'V S ADMINISTERED ON OR AFTER THE FOURTH BIRTHDAY, A FOURTH DOSE IS NOT REQUIRED. FOLD VACCINE IS OMITTED FROM THE REQUIRED MMUNIZATIONS OF CHILDREN 18 YEARS OF AGE OR OLDER MEASLES. MUMPS. AND RUBELLA - I DOSE REQUIRED MMP COMBINED - 1 DOSE AT 12 MONTHS OF AGE OR OLDER AND IN 1968 OR LATER (FECOMMENDED AT 15 MONTHS) -OR- MEASLES SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER AND IN 1968 OR LATER (RECOMMENDED AT 15 MONTHS MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLO?(/1, RUBELLA SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER THE CHILDREN'. ALL AI-VHOPHIVE Dirt TNGL DING BIRTHIDATE MUST BE ENTERED. AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED PERSON ANA FOR THE CHILD TO ATTEND SCHOOL ist D I HAVE REV AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHILD HAS BEEN ADEQUATELY IMMUNIZED AGAINST DIPHTH R _ APOLIO. MEASLES, MUMPS. AND RUBELLA AS REQUIRED BY FLORIDA LAW FOR SCHOOL ATTENDANCE. SUITE 201 ROYAL PALM BEACH, FL 33411 PHONE Q,0 9 a PHYSICIAN OR CLINIC NAME 'PLEASE PRINT) R AUTHIRIZED NATURE DATE EFTA01710357  STATE OF FLORIDA DEPARTMENT OF HEALTH If REHABILITATIVE SERVICES STUDENT HEALTH EXAMINATIONS 7- ao Lj sex rh N A JSe zadi Scalp /4 Eyes 5. Visua Acuity I 4-I! t s 1--- G Ears 7.luditorett Latty & 8. Ncse / Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs II. Heart 12 Abdomen 13. Genitals and Alus 14. Muoculo SkcIval 15. Neurological 16. Alertness 17 Emotional / Mental/ Behavior Prob.) 18. Handicap, physical/ cthec (Specify) 19. Activity Rostricaans ISOM( r) 20. Abuse. substance physical / emcoonal 21. Nutrition 22. Other B. HEALTH HISTORY Serious Illnesses Injules explain) (attach rarrative if adclutianal space needed) C. LABORATORY Hemoak>bin/Flematccse Stool (O PI 1 I-17: I:2 DitIthrei -. .. Tuberculin Sickle Cell ctri.,L.O5.; NAMI: TITLE ADD (PiirsiiA'0t(m) PALM BEACH BLVD. 30 . 9 L SUITE 201 Date ROYAL PALM sena'. FL 33411 F. Obsolete. previous 'dittos.) (Stock Nunber: 5744-000-3040-2) EFTA01710358  STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES Special Health CUMULATIVE SCHOOL HEALTH RECORD Problems • See (This form is not intended for physician's use) Narrative__ Name Race Lc) Sex F School Address Father's Name fi r. Mother's Name Date of Birth Al/. / El ■ Place of Birth (4 es4 -Palo .3eGeh F1 Birth Recorded. Yes El— No 0 Immunization Certification: Yes Er No 0 Special Immunization Programs A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES K 1 2 3 Screening and Screening Screening Screening Outcome Outcome Outcome Outcome Assessment c cn Referral Referral Referral IL3 Date Date Date Grades c O m ,,, IS K-3 00 0 Z.5 tr (I) Vision Hearing Height, Weight & Graphing Nutrition I Dental Health Mental Health Communicable Disease Records Review Physical Assessment Other Other 4 5 6 7 8 Screening and a crooning creening Screening CD 'Outcome Outcome Outcome Outcome Assessment Referral Referral 1. 4. E c To c To Date O "E 0 Date Date Grades c2 '- r, O co €3) 4-8 O , Et, 0 0 cr s a ILI:, t.) I u) I Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Scoliosis Other Other L EFTA01710359  1 cTI inENT HEALTH EXAMINATIONS 7/‘/T3 Date Students Full Name Phone Age Race Sex Address Girth ate Nans of P e 1 or ds A. HEALTH EXAMINATION Hear Pressure (/) Normal-N. Abnormal-A comment I: Aoriormai rindings, Dy numoer 1 Appearance 2 SiuniNose 3 Head/Scalp 4 Eyes 5. Visual Acuity IF & LI 6. Ears 7 Auditory Acuity (R & 8 Nose / Throat 9 Mount Teeth and Gums 10. Chest r Lunos 11. Heart 12 Abdomen 13. Genitals and Anus 14. Mu5W10•Skelelal 15. Neurological 16. Alertness 17. Emotional Mental/ Behavior Prob1 18 NandCall,DblyS/cal/ other ISPeCI1Y) 19. Actsfity Restrictions iSpeciry) 20. Abuse. substance/ Physical / emotional 21. Nutrition 22. Other B. HEALTH HISTORY sv,..us (Messes Injuries: explain) (attach narrative d additional space needed) C. LABORATORY (as indicated) t- rnoglcbin/Hemafocrit Stool (O & d Tuberculin test: LP 1C1 Sickle Cell NAME: TITLE: ADDRESS: (Please Print) Authorized Signature 7A /7 5 Date OH 3040. 10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2) EFTA01710360  STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES Special Health CUMULATIVE SCHOOL HEALTH RECORD Problems - See Narrative (This form is not intended for physician's use) Name. Race th Sex F School eatewnese 77(.1 45 1 Adore Father's Name Mother's Narre MalL Date of Birth Place of Birth CO e54 Fl Birth Recorded: Yes 9 No ❑ Immunization Certification: Yes a' No D Special Immunization Programs A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES K I 2 3 Screening and Screening Screening Screening Screening Outcome Outcome Outcome Outcome Assessment .......— To 7! -5 1.a. Date Date Date Date Grades 0 IS O To K-3 t:i co 71) 0 CC cc cc cc Vision Hearing Height, Weight & Graphing Nutrition Dental Health - r at Mental Health Ccmmunicable Disease Records Review Physical Assessment Other Other 4 5 6 7 8 Screening and cr) a, 3creening 3creening Outcome