Revised 9/2015
HEALTH SERVICES SCREENING FORM
Screening
Student_____________________________________________ DOB_____________ Grade _____ Date _____
_____
SID# _______________________ School ________________________________ Is the student homebound? ____Yes _____No
Parent(s)___________________________________ Home Phone___________________ Alternate Number _________________
Form completed by
CPSB Employee Signature
Position ___________________
Return to ___________________________________________________________ By (date of IEP/Re-eval) __________________
Reason:
Preschool Clinic
SBLC/Initial
Interim IEP
Annual IEP
Respond YES or NO to items 1 - 11 below:
DOES THE STUDENT
A. Description of Medical Need, Diagnosis or Treatment
1. Experience severe allergic reactions that require immediate medications,
i.e., Epi-Pen? Drug allergies: ___________________________________
YES
NO
Re-eval
Re-eval New Concern
COMMENTS
(Explain in detail all YES responses)
2. Have a current medical diagnosis (i.e., diabetes, tuberculosis, ADD,
seizures, cystic fibrosis, asthma, muscular dystrophy, liver disease,
digestive disorders, respiratory disorders, hemophilia)?
Condition: _________________________________
Diagnosis:
3. Receive medical treatments during or outside the school day (i.e.,
oxygen, gastrostomy care, tracheostomy care, suctioning, injections,
insulin pump)?Condition:___________________________
4. Experience frequent absences due to illness or frequent hospitalizations?
Treatment:
5. Receive ongoing prescribed medication at home or school for physical or
emotional problems (i.e., seizure, heart condition, allergy, asthma, cancer,
depression, ADHD)?
Medication:
Physician:
Physician:
Physician:
Hospital:
Medication is dispensed: __at home __at school
B. Environmental Adjustments Required Within the Educational Setting
6. Require adjustments of the school environment or schedule due to a
health condition (i.e., seizures, limitations in physical activity, periodic
breaks for endurance, part-time schedule, building modifications for
access)?
7. Require environmental adjustments to classroom or school facilities (i.e.,
temperature control, refrigeration/ medication storage, availability of
running water, wheelchair accessibility)?
8. Require major safety considerations (i.e., special precautions in lifting,
positioning, special transportation, emergency plan, special safety
equipment, special techniques for positioning, feeding)?
9. Require an emergency plan (Consider: seizure disorders, diabetes,
asthma, and severe allergic reactions)?
10. Requires a physician prescribed special diet (i.e., blended, soft, low salt,
low fat, liquid supplement, food allergies)?
C. Assistance/Modifications Required for Activities of Daily Living
11. Require assistance with activities of daily living (i.e., eating, toileting,
walking, diapering)?
HEARING
Yes
No
VISION
Yes
-history of acute ear infections?
-history of acute eye infections?
-history of chronic ear infections?
-history of chronic eye infections?
-persistent head colds?
To receive a Health Services Assessment, there must be a check in the yes
column in any section.
Asthma, diabetes, seizures always require an emergency health plan.
Does student require a health services assessment?
WHITE COPY to nurse with current medicals attached
PINK COPY to IEP Folder
YELLOW COPY to PA records Instruction (if Exceptional student)
yes
no
Attempts made by staff to secure medical
records/diagnosis:
Date/Action: _________________________
Date/Action: _________________________
Date/Action: _________________________
No