Health Assessment Record State of Connecticut Department of Education Health Assessment Record To Parent or Guardian: In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests information from you which will also be helpful to the health care provider when he or she completes the medical evaluation.Student Name(Required) First Last Birth Date(Required) MM slash DD slash YYYY Gender(Required) Female Male Other Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Name(Required) First Last Home PhoneCell Phone(Required)School/Grade(Required) Race/Ethnicity American Indian/Alaskan Native Hispanic/Latino Black, not of Hispanic origin White, not of Hispanic origin Asian/Pacific Islander Other Primary Care Provider(Required) Health Insurance Company/Number or Medicaid Number Does your child have health insurance?(Required)If your child does not have health insurance, call 1-877-CT-HUSKY Yes No Does your child have dental insurance?(Required) Yes No To be completed by parent/guardian. Please answer these health history questions about your child before the physical examination.Any health concerns(Required) Yes No If yes, please explain(Required) Allergies to food or bee stings(Required) Yes No If yes, please explain(Required) Allergies to medication(Required) Yes No If yes, please explain(Required) Any other allergies(Required) Yes No If yes, please explain(Required) Any daily medications(Required) Yes No If yes, please explain(Required) Any problems with vision(Required) Yes No If yes, please explain(Required) Uses contacts or glasses(Required) Yes No If yes, please explain(Required) Any problems hearing(Required) Yes No If yes, please explain(Required) Any problems with speech(Required) Yes No If yes, please explain(Required) Hospitalization or Emergency Room visit(Required) Yes No If yes, please explain(Required) Any broken bones or dislocations(Required) Yes No If yes, please explain(Required) Any muscle or joint injuries(Required) Yes No If yes, please explain(Required) Any neck or back injuries(Required) Yes No If yes, please explain(Required) Problems running(Required) Yes No If yes, please explain(Required) “Mono” (past 1 year)(Required) Yes No If yes, please explain(Required) Has only 1 kidney or testicle(Required) Yes No If yes, please explain(Required) Excessive weight gain/loss(Required) Yes No If yes, please explain(Required) Dental braces, caps, or bridges(Required) Yes No If yes, please explain(Required) Concussion(Required) Yes No If yes, please explain(Required) Fainting or blacking out(Required) Yes No If yes, please explain(Required) Chest pain(Required) Yes No If yes, please explain(Required) Heart problems(Required) Yes No If yes, please explain(Required) High blood pressure(Required) Yes No If yes, please explain(Required) Bleeding more than expected(Required) Yes No If yes, please explain(Required) Problems breathing or coughing(Required) Yes No If yes, please explain(Required) Any smoking(Required) Yes No If yes, please explain(Required) Asthma treatment (past 3 years)(Required) Yes No If yes, please explain(Required) Seizure treatment (past 2 years)(Required) Yes No If yes, please explain(Required) Diabetes(Required) Yes No If yes, please explain(Required) ADHD/ADD(Required) Yes No If yes, please explain(Required) Family HistoryAny relative ever have a sudden unexplained death (less than 50 years old)(Required) Yes No If yes, please explain(Required)For illnesses/injuries/etc., include the year and/or your child's age at the time. Any immediate family members have high cholesterol(Required) Yes No If yes, please explain(Required)For illnesses/injuries/etc., include the year and/or your child's age at the time. Is there anything you want to discuss with the school nurse?(Required) Yes No If yes, please explain(Required)Please list any medications your child will need to take in school:All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardianBy signing below, I give permission for release and exchange of information on this form between the school nurse and health care provider for confidential use in meetings my child's health and educational needs in school. Signature of Parent/Guardian(Required) Today's Date(Required) MM slash DD slash YYYY Please click SUBMIT when complete
