Health Services Screening Form

Revised 7/2017

HEALTH SERVICES SCREENING FORM

Screening

Student______DOB______Grade _____ Date ______

State ID# ______School ______Is the student homebound? ____Yes _____No

Parent(s)______Home Phone______Alternate Number ______

Form completed byCPSB Employee Signature Position ______

Return to______By (date of IEP/Re-eval) ______

Reason: Preschool Clinic SBLC/Initial Interim IEP Annual IEP Re-eval Re-eval New Concern

Respond YES or NO to items 1 - 11 below:
DOES THE STUDENT / YES / NO COMMENTS
(Explain in detail all YES responses)
A. Description of Medical Need, Diagnosis or Treatment
1. Experience severe allergic reactions that require immediate medications,
i.e., Epi-Pen? Drug allergies: ______
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:
Physician:
3. Receive medical treatments during or outside the school day(i.e.,
oxygen, gastrostomy care, tracheostomy care, suctioning,injections,
insulin pump)?Condition:______/ Treatment:
Physician:
4. Experience frequent absences due to illness or frequent hospitalizations? / Hospital:
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:
Medication is dispensed: __at home __at school
B. Environmental Adjustments Required Within the Educational Setting
6. Require adjustments of the school environment orschedule due to a
health condition (i.e., seizures, limitations in physical activity, periodic
breaks forendurance, part-time schedule, building modificationsfor
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: seizuredisorders, diabetes,
asthma, and severe allergic reactions)?
10. Requires a physician prescribed special diet (i.e., blended, soft, low salt,
low fat, liquidsupplement, 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 / No
-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? yes no
WHITE COPY to nurse with current medicals attached
PINK COPYto IEP Folder
YELLOW COPY to PA records Instruction (if Exceptional student) / Attempts made by staff to secure medical records/diagnosis:
Date/Action: ______Date/Action: ______
Date/Action: ______