Department of Education
Student’s Health Record
Day
Year
/
/
/
/
/ /
/ /
Date
Results
(mm)
❑
❑
❑
Hearing Problems
Heart Disease
Hemophilia
Physician, APRN, PA, or Clinic
Chest X-Ray
Location
Results
*OFFICE USE ONLY (Rev. 2010)
❑
❑
❑
Hypertension
JRA Arthritis
Rheumatic Heart
Varicella
Immunity
Secondary to
Disease (DATE)
❑
❑
❑
Seizures
Sickle Cell Anemia
Skin Problems
❑
❑
❑
Vision Problem
❑
/
/
/
/
/
/
See Results Below
Completed
PPD Screening
(Check if Yes)
Reviewed
Immunization
Record
(Check if Yes)
Nutrition
Scoliosis
Provider’s Stamp
or Printed Name
Provider’s Signature
Immunizations (Vaccines, Dates Given: Month/Day/Year)
DTaP, DTP, DT,
Tdap or Td
Type
Polio
(IPV or OPV)
Type
Hib (Haemophilus
influenzae type b )
Pneumococcal
Conjugate
Dental Examination
Dental Check-Up
Entry Date
Medical Status
Skin
Nervous
System
Teeth
Nose
Throat
Ears
R. L. R. L.
Eyes
Vision Hearing
/ /
/ /
Entry Date
Student Address Label
/
/
/
/
Allergies:
Tuberculosis Examination
Date
Read
Elementary:
/
/
/
/
Physician’s Examination Code: N-Normal; A-Abnormal; C-Corrected; R-Receiving Care
Mantoux Test (Intradermal)
Date
Given
Entry Date
(Father/Guardian)
Cancer/Leukemia
Chronic Cough/Wheezing
Diabetes
Blood
Pressure
BMI
Weight
Height
Grade
Date
Preschool:
High:
(Mother/Guardian)
❑
❑
❑
❑
❑
Intermediate/Middle: Entry Date
Please complete the following sections (CHECK IF YES)
Allergy (type)
Asthma
Behavioral Problems
Male
Abdomen
Month
Parent’s Name
(Middle Initial)
Heart
Birthdate
(First)
Female
Extremities
(Last)
Lungs
Name
Hepatitis B
Date
Date
Type
Date
Type
Date
Type
Date
MMR
Date
Hepatitis A
Date
Other
Other
Type
Date
Type
Date
Physician, APRN, PA or Clinic
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Varicella
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Health History Comments: Include Referrals and Reports. Recommendation for significant findings.
(Please Print)
Date
Signature & Title
STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 4/10, RS 10-1369 (Rev. of RS 09-1051)
Date
Signature & Title