Health Information
Student Name:
Date of Birth:
Grade Level:
 

Please enter all dates in mm/dd/yyyy format.
HEALTH INFORMATION
Dental Exam Date:
Dental Exam Result:
Hearing Test Date:
Hearing Test Result: Right Ear: Left Ear:
Physical Exam Date:
Physical Exam Result:
Scoliosis Screening Date:
Scoliosis Screening Result:
TB Skin Test Date:
TB Skin Test Result:
Vision Test Date:
Vision Test Result: Right Eye:   Left Eye:
 

 
MEDICAL ALERT INFORMATION
 
Medical Alert Date:
Alert Type:
Alert Level:
Alert Name:
 

 
MEDICATION INFORMATION
 
Name of Medication:
Date Medication Prescribed:
 

Health Information: Enter the most current physical exam, vision, hearing and dental screens and TB skin and scoliosis test results for the student. Indicate all dates in the dd-mm-yy format.

Examples of Physical Exam and Screening Results

 

Physical Exam Result—Normal or Within Accepted Range

 Scoliosis Screening—Normal

Hearing Test Result—Left ear—Normal, Right ear—Normal

TB Skin Test Result—Negative

Vision Test Result—Left eye—20/30 Right eye—20/20

Dental Exam Result—Normal

Medical Alert Information—Indicate the date of the medical alert. This can be a reporting date or the contact date. Indicate an Alert Type as Condition or Allergy as reported by the school nurse or other health provider. To relate another associated condition indicate Related Condition. Indicate an Alert Level as Chronic or Acute as reported by the school nurse or other health provider. Provide a Medical Alert Name such as Diabetes

Medication Information—Indicate the name of the medication taken by the student. Indicate the date on which the medication was prescribed for the student.

FAX COMPLETED FORM TO BONNIE QUINTANA IN FEDERAL PROGRAMS (806) 766-2226

NGS Implementation Guidelines for School Districts and Education Service Centers                                                         Revised: August 19, 2008