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Child and Family Agency

Child and Family Agency

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Health Assessment Record


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)
MM slash DD slash YYYY
Gender(Required)

Address
Parent/Guardian Name(Required)
Race/Ethnicity

Does your child have health insurance?(Required)
If your child does not have health insurance, call 1-877-CT-HUSKY
Does your child have dental insurance?(Required)

To be completed by parent/guardian. Please answer these health history questions about your child before the physical examination.

Any health concerns(Required)
Allergies to food or bee stings(Required)
Allergies to medication(Required)
Any other allergies(Required)
Any daily medications(Required)
Any problems with vision(Required)
Uses contacts or glasses(Required)
Any problems hearing(Required)
Any problems with speech(Required)
Hospitalization or Emergency Room visit(Required)
Any broken bones or dislocations(Required)
Any muscle or joint injuries(Required)
Any neck or back injuries(Required)
Problems running(Required)
“Mono” (past 1 year)(Required)
Has only 1 kidney or testicle(Required)
Excessive weight gain/loss(Required)
Dental braces, caps, or bridges(Required)
Concussion(Required)
Fainting or blacking out(Required)
Chest pain(Required)
Heart problems(Required)
High blood pressure(Required)
Bleeding more than expected(Required)
Problems breathing or coughing(Required)
Any smoking(Required)
Asthma treatment (past 3 years)(Required)
Seizure treatment (past 2 years)(Required)
Diabetes(Required)
ADHD/ADD(Required)

Family History

Any relative ever have a sudden unexplained death (less than 50 years old)(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)
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)
All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian
By 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.
MM slash DD slash YYYY

Please click SUBMIT when complete

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