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The Florida Health form is an essential document designed to ensure that children receive the necessary health evaluations before entering school. This form serves multiple purposes, beginning with the collection of the child's medical history, which parents or guardians must complete. It asks about general health concerns, allergies, medications, and any previous hospitalizations or significant injuries. Additionally, the form highlights the importance of a comprehensive health examination conducted by a qualified professional, which is mandated by state law. Local school districts may impose additional requirements, making it crucial for parents to stay informed. The form also includes recommendations for prekindergarten and kindergarten children, urging parents to seek vision, dental, and hearing screenings to identify any potential issues that could affect learning. Finally, a section is dedicated to the medical evaluation, which must be completed by the child's healthcare provider. This part includes vital statistics and screening results, ensuring that any health conditions that may impact the child's educational experience are documented and addressed. Overall, the Florida Health form is a comprehensive tool that facilitates communication between parents, healthcare providers, and school personnel, ultimately supporting the child's health and educational needs.

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STATE OF FLORIDA

School Entry Health Exam

To Parent/Guardian: Please complete and sign Part I — Child’s Medical History.

State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determined by local school districts.

(Please Print)

Name of Child (Last, First, Middle)

 

Birth Date

Sex

Address (Street)

 

School

Grade

City and ZIP Code

Home Telephone Number

Parent/Guardian (Last, First, Middle)

 

PART I CHILD’S MEDICAL HISTORY

To Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left. (Please explain any “Yes” answers in the space provided below.)

1.Yes No Any concerns about general health (eating and sleeping habits, weight, etc.)?

2.Yes No Any other specific illness or social/emotional or behavioral problems?

3.Yes No Any allergies (food, insects, medication, etc.)?

4.Yes No Any prescription medication (daily or occasionally)?

5.Yes No Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?

6.Yes No Any hospitalization, operation, or major illness (specify problem)?

7.Yes No Any significant injury or accident (specify problem)?

8.Yes No Would you like to discuss anything about your child’s health with a school nurse?

To Parent/Guardian: Please explain any “Yes” answers from above.

I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this form provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing school health services in the district for the limited purpose of meeting my child's health and educational needs.

Signature of Parent/Guardian

 

Date

Partnership for School Readiness Recommendations for Prekindergarten and Kindergarten

To Parent/Guardian: Please obtain the services listed below in order to find any problems. Please work with your health care provider to correct or treat any problems that may reduce your child’s ability to learn in school. (These services are recommended but not required.)

 

1. Comprehensive Vision Examination (3-5 years of age)

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Provider:

 

 

 

 

 

 

(check one) Optometrist

Ophthalmologist

 

 

 

 

 

 

 

2. Comprehensive Dental Examination

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist:

 

 

 

 

 

 

 

 

 

 

 

 

3. Hearing Screening

 

 

 

Please describe any corrective action for any problems detected and

 

Date of Exam:

 

 

 

any accommodations required.

 

Results of Exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Provider:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DH3040-CHP-07/2013

Name of Child (Last, First, Middle)

School Entry Health Exam Page 2 of 2

Birth Date

PART II MEDICAL EVALUATION

To be completed and signed by the Health Care Provider ONLY:

The child named above has had a complete history and physical exam on the following date:

 

 

 

 

 

(Exam must be within one year of enrollment)

 

 

 

 

 

 

 

Month

 

 

Day

 

Year

 

Screening Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

Weight:

 

BMI%:

 

 

B/P:

 

 

 

Hct/Hgb:

 

 

Lead:

 

 

 

Urinalysis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision - Without Glasses

 

Right 20/_____

 

Left 20/_____

Passed

 

Hearing – Right

 

Passed

Failed

 

Referred

 

 

 

 

 

 

 

 

 

 

 

 

Failed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision - With Glasses

 

Right 20/_____

 

Left 20/_____

 

 

Hearing – Left

 

Passed

Failed

 

Referred

 

 

 

 

Referred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross dental (teeth and gums)

Normal

 

 

Abnormal

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

Head/scalp/skin

 

 

 

Normal

 

 

Abnormal

 

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

 

Eyes/Ears/Nose/Throat

 

Normal

 

 

Abnormal

 

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

 

Chest/Lungs/Heart

 

Normal

 

 

Abnormal

 

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

Normal

 

 

Abnormal

 

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

 

Postural assessment

 

Normal

 

 

Abnormal

 

 

 

 

 

 

 

Refer/Tx:

 

 

 

 

 

 

 

 

 

TB risk assessment done

(Please review Targeted Testing Guidelines listed below.)

This child has the following problems that may impact the educational experience:

Vision

Hearing

Speech/Language

Physical

Specify:

Social/Behavioral

Cognitive

This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below.

(This form will be stored in the child’s Cumulative Health Folder and may be accessed by both school and health personnel.)

Recommendations (Attach additional sheet if necessary):

(Please Check One)

This child may participate fully in school activities including physical education.

This child may participate in school activities including physical education with the following restriction/adaptation. (Specify reason and restriction)

Signature/Title of Health Care Provider

Date

Address (Please print or stamp)

___/___/___

 

Name (Please print or stamp)

 

 

 

 

 

Tuberculosis Targeted Testing Guidelines for Health Care Providers

Tuberculosis Infection Risk:

Review the following risks and administer a Mantoux TB skin test if child is in one or more categories. The TB test is administered confidentially as part of the health examination. Do not record administration of any TB test or related information on this form.

Recent immigrant (< 5 years), frequent visitor to TB endemic areas

Close contact to active TB case

Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user

HIV+ or have other medical conditions that increase the risk to progress from infection to disease, e.g., chronic renal failure, diabetes, hematologic or any other malignancy, weight loss > 10% of ideal body weight, on immunosuppressive medications

Active TB Disease Risk:

Does the child exhibit signs/symptoms of tuberculosis (e.g. cough for three weeks or longer, weight loss, loss of appetite)?

If symptoms are present, work-up or refer for TB disease evaluation.

DH3040-CHP-07/2013

Form Specifications

Fact Name Details
Health Examination Requirement Florida law mandates that a health examination be conducted by a legally qualified professional before a child can enroll in school.
Local School District Authority Local school districts may impose additional requirements beyond the state law for school entry health exams.
Parental Consent The form requires a parent or guardian's signature, granting permission for school staff to review the child's health information for educational needs.
Medical Evaluation Completion The medical evaluation section must be completed and signed by a health care provider, confirming that the child has undergone a complete history and physical exam within one year of enrollment.

Florida Health: Usage Guidelines

Completing the Florida Health form is an essential step in ensuring your child's readiness for school. This form collects important health information that will be used to support your child's educational experience. Follow the steps below to fill out the form accurately.

  1. Begin by entering your child's name in the format of Last, First, Middle.
  2. Provide your child's birth date.
  3. Indicate your child's sex.
  4. Fill in your child's home address, including street, city, and ZIP code.
  5. List the school your child will be attending and their grade level.
  6. Enter your home telephone number.
  7. Provide your name as the parent or guardian in the format of Last, First, Middle.
  8. In Part I, answer questions 1 through 8 by checking "Yes" or "No" in the left column. If you answer "Yes" to any question, provide an explanation in the space provided below.
  9. Sign and date the form to give permission for the information to be reviewed by school staff.
  10. For the recommendations section, work with your health care provider to obtain the suggested services, including a vision examination, dental examination, and hearing screening. Document the results and any necessary accommodations.
  11. In Part II, have your health care provider complete the medical evaluation section, including the date of the physical exam and screening results.
  12. Ensure your health care provider indicates any health conditions that may require emergency action at school.
  13. Finally, have your health care provider sign and date the form, and provide their address and name.

Your Questions, Answered

What is the purpose of the Florida Health form?

The Florida Health form is required for school entry. It ensures that children receive a health examination by a qualified professional. This helps identify any health issues that may affect a child's ability to learn and participate in school activities.

Who needs to complete the Florida Health form?

Parents or guardians of children entering school must complete this form. It includes sections for the child's medical history and a medical evaluation by a health care provider.

What information is required from parents or guardians?

Parents or guardians need to provide the child's name, birth date, address, and contact information. They must also answer questions regarding the child's medical history, including any concerns about health, allergies, medications, and more.

What happens if a parent answers "Yes" to any questions in Part I?

If a parent answers "Yes" to any question, they should provide an explanation in the designated space. This information is important for school health personnel to understand any specific health needs or concerns.

Is a health examination mandatory?

Yes, state law requires a health examination by a qualified professional for school entry. Local school districts may have additional requirements, so it's important to check with the specific school.

What does Part II of the form entail?

Part II must be completed and signed by a health care provider. It includes a complete history and physical exam, along with screening results for vision, hearing, and other health assessments.

How recent must the health examination be?

The health examination must be conducted within one year of the child's enrollment in school. This ensures that the information is current and relevant.

What should parents do if their child has specific health conditions?

Parents should indicate any health conditions that may require emergency action at school. This includes conditions like allergies or seizures. This information will be stored in the child's Cumulative Health Folder for access by school and health personnel.

Are there any recommended services for children?

Yes, the form recommends services such as comprehensive vision and dental examinations, as well as hearing screenings. While these services are not mandatory, they can help identify issues that may affect a child's learning.

How is the information on the Florida Health form used?

The information provided on the form is reviewed and utilized by school staff and health personnel. It is used solely for the purpose of meeting the child's health and educational needs.

Common mistakes

  1. Incomplete Information: Failing to fill out all required fields, such as the child's name, birth date, or address, can lead to delays or complications in processing the form.

  2. Missing Signatures: Not signing the form can render it invalid. Ensure that the parent or guardian’s signature is present before submission.

  3. Neglecting to Explain "Yes" Answers: If any questions are answered with a "Yes," it is crucial to provide explanations. Omitting this information may hinder the understanding of the child's health needs.

  4. Incorrect Dates: Entering the wrong date for the health examination can create issues. The exam must be within one year of enrollment, so double-check the date.

  5. Inaccurate Health History: Providing incorrect or incomplete medical history can affect the child's care and educational experience. Be thorough and honest when detailing any health concerns.

  6. Ignoring Recommendations: Not following through with the recommended health services, such as vision or dental exams, can impact the child’s learning and development.

  7. Failure to Update Information: If there are changes in the child's health status after the form is submitted, it is important to update the school to ensure the child receives appropriate care.

  8. Not Consulting with Health Care Providers: Parents should work with health care providers to address any health issues. Not doing so may leave potential problems unaddressed.

  9. Overlooking Emergency Information: If the child has a health condition that requires emergency action, failing to specify this on the form can lead to serious consequences in a school setting.

Documents used along the form

When preparing for your child's school entry, several documents work alongside the Florida Health form to ensure a comprehensive understanding of their health needs. Each document serves a specific purpose and helps in assessing the child's readiness for school. Below are a few key forms that are commonly used in conjunction with the Florida Health form.

  • Immunization Records: This document provides a detailed account of all vaccinations your child has received. Schools require this information to ensure that your child is protected against preventable diseases and meets state immunization requirements.
  • Physical Examination Report: Conducted by a healthcare provider, this report outlines the results of a complete physical exam. It includes information on growth metrics, vision and hearing screenings, and any health concerns that may affect school participation.
  • Emergency Contact Form: This form lists individuals who can be contacted in case of an emergency involving your child. It typically includes names, phone numbers, and relationships to the child, ensuring that the school can quickly reach someone if needed.
  • Medication Authorization Form: If your child requires medication during school hours, this form must be filled out and signed by a parent or guardian. It details the medication, dosage, and administration times, ensuring that school staff can safely administer it.

Gathering these documents along with the Florida Health form will help facilitate a smooth transition into school. It ensures that your child receives the necessary support and care while they embark on their educational journey.

Similar forms

The Florida Health form is essential for school entry, but it shares similarities with several other important documents. Here’s a closer look at seven documents that have comparable features:

  • School Physical Examination Form: Like the Florida Health form, this document requires a comprehensive health evaluation by a qualified healthcare provider. It also includes sections for medical history and any specific health concerns related to school activities.
  • Immunization Record: This record is crucial for school entry, similar to the Florida Health form. Both documents track the child's health status and ensure they meet the necessary health requirements for attending school.
  • Individualized Education Program (IEP): An IEP outlines specific educational needs and accommodations for children with disabilities. Much like the Florida Health form, it includes detailed health information that can impact a child's learning experience.
  • Emergency Contact Form: This form gathers essential information about a child's health and emergency contacts. It parallels the Florida Health form by ensuring that school staff can respond appropriately in case of a health-related emergency.
  • Health Insurance Information Form: This document collects details about a child's health insurance coverage. Similar to the Florida Health form, it serves to facilitate access to necessary medical care and ensure that health needs are met.
  • Consent for Treatment Form: Parents or guardians sign this document to authorize medical treatment for their child. It shares similarities with the Florida Health form, as both require parental consent for health-related actions taken at school.
  • Health History Questionnaire: This form gathers detailed information about a child's past health issues and family medical history. It is akin to the Florida Health form in that it aims to identify potential health concerns that could affect the child's education.

Understanding these similarities helps highlight the importance of maintaining accurate health records for children in educational settings.

Dos and Don'ts

When filling out the Florida Health form, there are important dos and don’ts to keep in mind. Follow these guidelines to ensure the process goes smoothly.

  • Do provide accurate and complete information about your child's medical history.
  • Do check all relevant boxes for questions regarding your child's health.
  • Do explain any "Yes" answers clearly in the space provided.
  • Do ensure the health care provider completes and signs Part II of the form.
  • Don't leave any sections blank unless instructed; this could delay processing.
  • Don't provide false information, as it can have serious consequences for your child’s health care.
  • Don't forget to include your signature and date at the end of the form.
  • Don't assume all questions are optional; some are required by law for school entry.

Misconceptions

Misconceptions about the Florida Health form can lead to confusion among parents and guardians. Below are eight common misconceptions along with clarifications.

  • The form is optional for school entry. The Florida Health form is required by state law for school entry, as it documents a health examination by a qualified professional.
  • Only physical health is assessed. The form also addresses social, emotional, and behavioral health, ensuring a comprehensive view of the child's well-being.
  • Parents can skip questions if they don’t apply. All questions should be answered, even if the answer is “No.” This provides a complete medical history for the school.
  • Health care providers fill out the entire form. Parents or guardians must complete Part I regarding the child's medical history before the health care provider fills out Part II.
  • All information is shared publicly. The information on the form is confidential and is used solely by school and health personnel for educational and health purposes.
  • The form is only for new students. Returning students may also need to submit updated health information, especially if there are changes in their health status.
  • All recommended services are mandatory. The recommendations for additional services, such as vision and dental exams, are suggested but not required.
  • The form does not consider emergency health conditions. The form specifically asks about health conditions that may require emergency action at school, ensuring that staff are prepared to respond appropriately.

Key takeaways

Filling out the Florida Health form is an essential step for your child's school entry. Here are some key takeaways to guide you through the process:

  • Complete Part I: As a parent or guardian, you need to fill out Part I, which focuses on your child's medical history. This includes checking yes or no for various health concerns.
  • Be Honest: If you answer "Yes" to any question, provide detailed explanations. This information is crucial for school health personnel to understand your child's needs.
  • Health Examination Requirement: Florida law mandates that a health examination be conducted by a qualified professional. Ensure this is completed before submission.
  • Local School Districts: Be aware that additional requirements may be set by local school districts. Check with your child's school for any specific guidelines.
  • Recommended Services: The form suggests obtaining comprehensive vision, dental, and hearing examinations. While not mandatory, these services can help identify potential learning barriers.
  • Health Care Provider Signature: Part II must be completed and signed by a health care provider. This includes vital statistics like height, weight, and screening results.
  • Emergency Action Plans: If your child has health conditions requiring emergency action, clearly specify these on the form. This ensures the school is prepared to respond appropriately.
  • Confidentiality: Understand that the information provided will be stored in your child's Cumulative Health Folder and accessed only by authorized school and health personnel.
  • Follow-Up: Keep a copy of the completed form for your records. This can be helpful for future medical appointments or school inquiries.

By carefully completing the Florida Health form, you play a vital role in supporting your child's health and educational journey. Remember, the goal is to ensure a safe and supportive environment for learning.