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PPS-2K Rev.1/11 NORTH CAROLINA KINDERGARTEN HEALTH ASSESSMENT REPORT (Approved by North Carolina Department of Public Instruction and Department of Health and Human Services)
Please Print Clearly - See other side for more required information.
Please present completed form to your child's school.Child's ) Address: City: State: Zip: Parent/Guardian Name: Phone: Yes No Are you concerned about your child's health, weight, development or behavior?
behavior? (Please explain in the comments section)Has your child been seen by a provider for any health, weight, development or behavior concern?Comments: Parental Consent:
I agree to allow my child's health care provider and school personnel to discuss information on this form and allow the Department of Health and Human Services to collect and analyze information from this form to better Was this assessment completed in the child's regular health care provider's office? yes
no If no, please provide a copy to the child's parent to give to the child's regular health care provider.Health Care Professional's Certification
I certify that the information on this form is accurate and complete to the best of my knowledge.
Provider Stamp HereHas your child had a well-child visit or check-up in the last 12 months? Has your child had a dental exam by a dentist in the last 12 months? Medication
Child takes medicine for specific health conditions: List medication(s): COMPLETE Food: Insect: Medicine: Other: Practice/Clinic City, State & Zip: Personal Data
*Please bring your child's shot records with you to this visit * Requesting School Follow Up
- Attach a copy of the immunization record.
Personal Data Child's Birthdate:
(mm/dd/yyyy)Race: Hispanic or Latino Origin: 1 Yes 2 NoCounty of Residence: Zip Code: School your child will be attending:
1 Medicaid 2 Private Insurance/HMO 4
Other: Place where your child 1 Health Department 5 Other
gets regular health care: 2 Hospital Clinic
6 No regular place 3 Community Health Center 4 Private Doctor/HMO
Doctor/Practice Name:Date of Health Assessment: / /The health assessment must be conducted by a physician licensed to practice medicine, a physician's assistant as defined in General Statute 90-18, a certified nurse practitioner, or a public health nurse meeting the state standards for Health Check Services.
Immunizations - Attach a copy of the immunization record. Pertinent Illnesses, Risks or Developmental Problems:
(Please check all that apply) for Palsy
Dental Conditions Screening Results Screening Tool(s) Used:Developmental Domains:Within Normal Concern Identified Referred to Specialist1 PEDS 1 2 3 2 ASQ
Emotional/Social Problem Solving 4 PSC Language/Communication 5 ASQ-SE Fine Motor Skills Gross Motor Skills Hearing 1000 Hz 2000 Hz 4000 Hz Right Left Indicate Pass (P) or Refer (R) in each box.Refer means any failure at any frequency in either ear at 20dB.
Screening Tool Used:1 OAE 2 Audiometry
2 Scheduled for re-screen due to middle ear fluid. Re-screen appt.
in weeks.3 Referral to audiologist/ENT
(check if yes)
4 Child has previously diagnosed hearing loss.
Screening Please remember that vision screening is not a substitute for a comprehensive eye examination.1 Pass ( Acuity, Stereopsis, & Symptoms) 2 Referral to eye doctor (check if YES)
in either or both eyes, a two line difference between eyes,
unable to test, failed stereopsis, or signs of disease.
3 Child has a diagnosed vision condition and has had an eye
exam in the last 12 months.
Screening is not necessary.Physical Mass Index (BMI) - for age:
90 thPercentile ( % Back/ExtremitiesGenital Skin Other Non-White 2 White3 Black4 American Indian5 Chinese6 Japanese7 Hawaiian8 Filipino9 Other Asian10 UnknownPARENT COMPLETEHEALTH CARE PROVIDER COMPLETELead (Hx of Kidney DisordersHearing DisordersHeart ConditionsGenetic DisordersEnuresis (Daytime) DisordersTuberculosis At-Risk for TB
Speech/LanguageSickle Cell Anemia Seizures/ConvulsionsPrematurity (32 wks.EGA)Orthopedic LeftFar:Test Used: Was test performed with corrective > doneTrait StereopsisPassFailRefer if worse than 20/40 Acuity
3 No InsuranceDentist Name:20/20/.
Part II Medical EvaluationHealth Care Provider must complete and sign the medical evaluation and physical examinationHAR-3 REV.4/2012Signature of health care providerDate Signed Printed/Stamped Provider Name and Phone NumberPhysical ExamBirth DateStudent NameDate of ExamI have reviewed the health history information provided in Part I of this formNote: *Mandated Screening/Test to be completed by provider under Connecticut State Law*Height _____ in
./ _____%*Weight _____ lbs./ _____%BMI _____ / _____%Pulse _____*Blood Pressure _____ / / AbnormalNormalNormalOrthoDescribe Abnormal*Postural No spinalSpine abnormality: made*Vision ScreeningWith glasses20/Right Left20/Without glasses20/20/Referral madeType:*Auditory ScreeningRight LeftReferral madeType: Pass Pass Fail Fail*HCT/HGB:History of Lead : High-risk group? to Date or
Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED*Chronic Disease PersistentModerate PersistentSevere PersistentExercise induced If yes, please provide a copy of the Asthma Action Plan to School
Anaphylaxis source AllergiesIf yes, please provide a copy of the Emergency Allergy Plan to School History of AnaphylaxisNoYes
Epi Pen IType IIOther Chronic Disease:
Seizures NoYes, type: This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience.Explain: Medications (specify): student may:participate fully in the school program participate in the school program with the following restriction/adaptation: _____________________________ student may:participate fully in athletic activities and competitive sports
participate in athletic activities and competitive sports with the following restriction/adaptation: ____________ Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.Is this the students medical home?
NoI would like to discuss information in this report with the school nurse.MD / DO / APRN / PA*Speech (school entry only)Immunization RecordTo the Health Care Provider: Please complete and initial below.Vaccine (Month/Day/Year)
Note: *Minimum requirements prior to school enrollment.At subsequent exams, note booster shots only.PK and K (Students under age 5) PK and K (born 1/1/2007 or later)Required for 7th grade entryRequired K-12th gradeRequired K-12th gradeRequired K-12th gradeRequired K-12th grade PK and K (born 1/1/2007 or later)Required PK-12th grade2 doses required for K & 7th grade as of 8/1/2011Required for 7th grade entryPK students 24-59 months old given AHep 1Dose 2Dose 3Dose 4Dose 5Dose 6Disease Hx > aboveKINDERGARTEN
DTaP: At least 4 doses.The last dose must be given on or after 4th birthday.
Polio: At least 3 doses.The last dose must be given on or after 4th birthday.MMR: 2 doses given at least 28 day apart 1st dose on or after the 1st birthday.Hib: 1 dose on or after 1st birthday (Children 5 years and older do not need proof of Hib vaccination).Pneumococcal: 1 dose on or after 1st birthday (born 1/1/2007 or later and less than 5 years old).Hep A: 2 doses given six months apart-1st dose on or after 1st birthday.Hep B: 3 doses-the last dose on or after 24 weeks of age.Varicella: For students enrolled before August 1, 2011, 1 dose given on or after 1st birthday; for students enrolled on or after August 1, 2011
2 doses given 3 months apart 1st dose on or 1-6
DTaP /Td/Tdap: At least 4 doses.The last dose must be given on or after 4th birthday; students who start the series at age 7 or older only need a total of 3 doses of tetanus-diph-theria containing vaccine.Polio: At least 3 doses.The last dose must be given on or after 4th birthday.MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.Hep B: 3 doses the last dose on or after 24 weeks of age.Varicella: 1 dose on or after the 1st birthday
Tdap/Td: 1 dose of Tdap for students 11 yrs.or older enrolled in 7th grade who completed their primary DTaP series; For those students who start the series at age 7 or older a total of 3 doses of tetanus-diphtheria containing vac-cines are needed, one of which must be Tdap.
Polio: At least 3 doses.The last dose must be given on or after 4th birthday.MMR: 2 doses given at least 28 days apart 1st dose on or after the 1st dose for students
enrolled in 7th grade.Hep B: 3 doses-the last dose on or after 24 weeks of age.Varicella: 2 doses given 3 months apart 1st disease*.GRADES 8-12Td: At least 3 doses.
Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine one of which should be Tdap.Polio: At least 3 doses.The last dose must be given on or after 4th birthday.MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.Hep B: 3 doses-the last dose on or after 24 weeks of age.
Varicella: For students 13 years of age, 1 dose given on or after the 1st birthday.For students 13 years of age or older, 2 doses given at least *.* 9HULFDWLR-ing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.
Note: The Commissioner of Public Health may issue a temporary waiver to the schedule for active immunization for any vaccine if the National Centers for Disease Control and Prevention recognizes a nation-wide shortage of supply for such vaccine.ExemptionReligious _____
Medical: Permanent _____
Date _____ Recertify Date _________
Recertify Date _________
Recertify Date ________Initial/Signature of health care providerDate Signed Printed/Stamped Provider Name and Phone NumberMD / DO / APRN / PAHAR-3 REV.
4/2012Student Name: Date: Requirements for Newly Enrolled Students at Connecticut Schoo
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