Transcription of Department of Education Student S HealtH RecoRd
1 Student Address LabelMedical StatuS Department of EducationStudent S HealtH RecoRdNameBirthdate Parent s Name(Last) (First) (Middle Initial)Month Day YearPlease complete the following sections (CHECK IF YES)Physician, APRN, PA,ClinicCheck one box below, complete date assessment, test or x-ray was administered. Date:Date:Date:Date:Date:tubeRculoSiS evaluation/ // // /dental examination/ // /Dental Check-UpDental Check-UpPreschool: Entry DateElementary: Entry DateIntermediate/Middle: Entry DateHigh: Entry Date FemaleMale/ // // // /PHySician S examination code: n-noRmal; a-abnoRmal; c-coRRected; R-Receiving caReDate/ // /WeightGradeHeightExtremitiesScoliosisBl ood PressureSkinAbdomenLungsHeartTeethThroat NoseEyesHearingVisionNervous SystemR.
2 L. R. s Stamp or Printed NameProvider s SignatureReviewed Immunization RecoRd (Check if Yes)Varicella Immunity Secondary to Disease (DATE)Completed PPD Screening (Check if Yes) See Results Below/ // /BMIA llergy (type) Cancer/Leukemia Hearing Problems Hypertension Seizures Vision Problem Asthma Chronic Cough/Wheezing Heart Disease JRA Arthritis Sickle Cell Anemia Behavioral Problems Diabetes Hemophilia Rheumatic Heart Skin Problems Physician, APRN, PA or ClinicimmunizationS (vaccineS, dateS given: montH/day/yeaR) DTaP, DTP, DT, Tdap or TdPolio (IPV or OPV)Hib (Haemophilus influenzae type b )Pneumococcal ConjugateHepatitis BHepatitis AMMRHPVO therAllergies.
3 (Mother/Legal Guardian)(Father/Legal Guardian)Type DateType DateType DateType DateType DateType DateType DateType DateType Date/ / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / // / / / / / / / / / / /Varicella DateMeningococcal Conjugate DateNegative TB Risk AssessmentNegative test for TB infectionPositive test.
4 And negative chest x-rayHealth History Comments: Include Referrals and Reports. Recommendation for significant findings. (Please Print)STATE OF HAWAI I, Department OF Education , FORM 14, RS 18-0811, March 2018 (Rev. of RS 15-1154)Signature & TitleDateDateSignature & Titl
