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The State of Florida places a strong emphasis on the health and well-being of students entering the school system. With the implementation of the School Entry Health Exam form, parents and guardians play a critical role in ensuring their children meet the state's health requirements for school enrollment. This comprehensive form is divided into several parts, capturing vital information about a child's medical history, including general health concerns, specific illnesses, allergic reactions, prescription medications, and any history of hospitalizations or significant injuries. It also inquires about any concerns regarding a child’s vision, hearing, speech, and if there is anything the guardian would like to discuss with a school nurse. Furthermore, the form extends beyond simply gathering historical data, recommending preliminary health services such as vision, dental, and hearing screenings aimed at identifying and addressing any potential barriers to a child's learning ability. The second page of the form is dedicated to a medical evaluation conducted by a qualified health care provider, detailing the results of a physical examination, various screenings, and assessments necessary for identifying conditions that may impact a student's educational experience. The document also addresses the need for emergency action plans at school for children with specific health conditions. Conclusively, this form serves as a bridge between health care providers, parents, and the educational system to ensure each child is afforded the opportunity to succeed academically without being hindered by unaddressed health issues.

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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

Document Overview

Fact Name Description
Purpose of the Form The Florida Health Form is required for school entry and is designed to assess the health of children to ensure they are ready for school activities. It includes a comprehensive health exam and a review of the child’s medical history.
Governing Law State law mandates the health examination for school entry, implying that the form adherence is regulated by Florida state statutes concerning school health requirements.
Components of the Form The form is divided into two main parts: Part I — Child’s Medical History, which is completed by the parent or guardian, and Part II — Medical Evaluation, which must be completed by a legally qualified health care provider.
Additional Health Services While not mandatory, the form also recommends obtaining a comprehensive vision examination, dental examination, and hearing screening to identify any issues that may affect the child’s learning ability.

Instructions on How to Fill Out Florida Health

Filling out the State of Florida School Entry Health Exam form is an important step in ensuring your child is ready and eligible to attend school in Florida. This form, essential for school entry, must be filled out accurately to reflect your child’s health history and current health status. It is divided into two main parts: the first to be completed by the parent or guardian, and the second by a legally qualified health care provider. The instructions below guide you through the process of completing this form.

Part I — Child’s Medical History (To be completed by Parent/Guardian)

  1. Write the child's full name (Last, First, Middle), birth date, sex, home address (Street, City, ZIP Code), current school grade, and home telephone number.
  2. Indicate the name and full name of the parent/guardian completing this form.
  3. Answer questions 1 through 8 regarding the child’s medical history by checking “Yes” or “No”. These questions cover concerns about general health, specific illnesses or problems, allergies, medications, issues with vision, hearing, or speech, past hospitalizations or surgeries, significant injuries or accidents, and any health topics you wish to discuss with a school nurse.
  4. Explain any “Yes” responses in the space provided, detailing the concern or condition, treatments received, and any ongoing health management needs.
  5. Sign and date the form at the bottom of Part I to verify the information provided and authorize its review by school and health personnel.

Part II — Medical Evaluation (To be completed by Health Care Provider)

The second part of the form must be taken to your child’s health care provider for completion. It includes a comprehensive assessment of your child’s health including a physical examination, and screenings for vision, hearing, and dental health among others. Ensure that you provide the form to the health care provider and retrieve it after completion for submission to your child’s school.

Once both parts of the Florida School Entry Health Exam form have been completed:

  • Check the form for completeness and accuracy.
  • Make a copy of the completed form for your records.
  • Submit the original form to your child's school before or upon enrollment as required.

Following these steps ensures the necessary health information is accurately communicated to your child's school, supporting a smooth transition into the school system and the provision of any necessary health accommodations or services.

Listed Questions and Answers

What is the purpose of the Florida Health form?

The Florida Health form serves as a comprehensive health assessment tool to ensure that a child meets the state's health examination requirements for school entry. This process involves a detailed review of the child's medical history, a physical examination, and assessments for vision, hearing, and dental health, among others. The ultimate goal is to identify and address any health issues that might hinder the child's ability to thrive in the school environment.

Who is required to complete the Florida Health form?

All children entering school in Florida for the first time are required to have the Florida Health form completed. This requirement is part of the state law ensuring that students are healthy and ready to participate fully in school activities.

What information must a parent or guardian provide on the form?

Parents or guardians are tasked with filling out Part I of the form, which gathers detailed medical history about the child. This section includes questions about general health, allergies, medications, and any past hospitalizations or surgeries. It's a critical step to inform school health personnel about the child’s health needs and any special accommodations that may be necessary.

What parts of the form must be completed by a health care provider?

Part II of the form is exclusively for completion by a legally qualified health care provider. It includes the results of the child's physical examination, screening outcomes such as height, weight, body mass index (BMI), and assessments related to vision, hearing, and dental health. This part confirms the child's overall health and readiness for school.

Is there a deadline for submitting the Florida Health form?

While specific deadlines can vary by school district, generally, the form should be completed and submitted before or at the time of the child’s school enrollment. It’s important to check with your local school district for the exact timing.

What if a child has a health condition that requires special attention at school?

The Florida Health form allows parents and health care providers to outline any health conditions that might require emergency actions or special accommodations at school. This information is crucial for the school staff to ensure they are prepared to support the child’s health and educational needs appropriately.

Are vision and hearing screenings mandatory?

While comprehensive vision and dental examinations are recommended but not required by the state, vision and hearing screenings as part of the physical examination are essential components of the form. These screenings play a significant role in identifying any problems that might affect the child's learning experience.

What happens if a health problem is identified?

If a health issue is detected during the examination or through the medical history, the form guides parents to consult with their health care provider for further evaluation, treatment, or both. The objective is to address any health concerns that could impact the child’s ability to learn effectively.

Where does the Florida Health form go after it's completed?

Once filled out, the form should be submitted to your child’s school, where it will become a part of their Cum,ulative Health Folder. This ensures that school and health personnel can access the information to meet the student’s health and educational needs.

Common mistakes

Filling out the Florida Health form for school entry can be tricky. Mistakes in filling out this form can delay the process. Here are seven common errors people make:

  1. Not completing Part I — Child’s Medical History in its entirety. Parents or guardians sometimes leave out information here, forgetting that even minor health concerns should be reported.

  2. Missing the signature and date at the end of Part I. This oversight can render the form incomplete, as the parent’s or guardian's authorization is crucial for the form’s validity.

  3. Entering incorrect or outdated information. Mistakes such as the wrong birth date, address, or home telephone number can cause confusion and delays.

  4. Skipping the explanation part for any "Yes" answers in Part I. It's critical to provide details on any checked "Yes" options to ensure the school can accommodate the child's needs properly.

  5. Leaving the screening results section in Part II blank or incomplete. This section is for the health care provider to fill out, but parents/guardians should ensure that it's fully completed before submitting.

  6. Not attaching additional sheets when necessary. If there’s more information or recommendations from the health care provider that don't fit in the provided space, some forget to add extra pages.

  7. Failure to clearly indicate any health conditions that require special attention at school under the recommendations section. This could lead to a lack of necessary support or accommodations for the child.

Avoiding these mistakes can smooth the submission process, ensuring that the school has all the necessary details to support the child’s health and educational needs effectively. Always review the form carefully before submission.

Documents used along the form

When managing health-related forms for school entry in Florida, it's common to handle multiple documents that facilitate a smooth and compliant process. Besides the Florida School Entry Health Exam form, numerous other documents play crucial roles in ensuring students meet all health requirements and receive the appropriate care and accommodations they may need during their school life.

  • Immunization Records: These documents prove that the child has received vaccinations required by law for school entry, showcasing protection against diseases like measles, mumps, and tetanus.
  • Emergency Medical Authorization Form: This enables parents to authorize emergency medical treatment for their child in case of an incident during school hours when they cannot be reached immediately.
  • Medication Administration Form: For students who need to take medication during school hours, this document provides permission and instructions for school staff to administer these medicines.
  • Vision Screening Results: Detailed findings from a vision test, usually conducted by an optometrist or ophthalmologist, indicating whether a child needs glasses or other corrective measures.
  • Dental Examination Record: Represents a comprehensive check-up of a child’s dental health by a certified dentist, noting any issues and the recommended treatments or interventions.
  • Hearing Screening Results: Documents the outcomes of hearing tests, identifying potential hearing issues that may affect a student's learning process, with recommendations for further evaluation or treatment if necessary.
  • Individualized Education Program (IEP) or 504 Plan: For students with disabilities, these documents outline the specialized educational strategies, accommodations, or services required to support their learning.
  • Birth Certificate: Used to verify a student's age and is often a requirement for initial school registration.
  • Proof of Residence: Confirms the child’s residential address for determining the appropriate school district and conforms to district residency requirements.
  • (K)School Physical Examination Form: A more comprehensive medical evaluation than the basic screening, this form might be required for participation in sports or other activities, detailing a child’s physical fitness for such engagements.

Together, these forms and documents ensure that school administration and health personnel have a full picture of a student’s health and wellness needs. Proper completion and submission of these documents facilitate a safer, more accommodating, and legally compliant school environment for every child.

Similar forms

The Florida Health Form, required for school entry in the state of Florida, shares similarities with various other documents that track and monitor the health conditions and requirements of children. These documents are essential in ensuring children's wellness in environments such as schools, sports, and other extracurricular activities. By examining how the Florida Health Form parallels these documents, we can appreciate its broader role in child health and safety oversight.

One document similar to the Florida Health Form is the Pediatric Annual Physical Examination Form commonly used by pediatricians. This form captures a child's comprehensive health status, including medical history, current medications, and the outcomes of physical examinations such as height, weight, BMI, and vital signs, closely mirroring the Florida form's Part II. Both forms require health care provider verification affirming the child's health status and any special conditions that might affect their schooling experience, like allergies or physical restrictions. This similarity ensures a continuum of care and information sharing between healthcare providers and educational institutions, prioritizing the child’s health in both medical and educational settings.

Another analogous document is the Sports Pre-Participation Physical Evaluation. This form is specifically designed to assess a child's fitness to participate in sports and physical education, focusing on areas such as heart health, joint mobility, and overall physical fitness. Similar to the Florida Health Form, it includes sections for medical history reviewed by parents and a physical evaluation conducted by a health care provider. Both ensure that children who have specific health conditions are appropriately accommodated in school activities, emphasizing the importance of safety in physical exertion. The main goal is to prevent injuries and ensure that any existing health issues are managed properly during school-sponsored physical activities.

A third similar document is the Immunization Record Form. Although primarily focused on tracking vaccinations, it is critical for school entry in many jurisdictions, akin to the Florida Health Form. Both forms serve as gatekeepers for child safety in the school environment, ensuring students meet health requirements that protect themselves and others from communicable diseases. While the Immunization Record Form is more narrowly focused, it complements the Florida Health Form by providing a complete picture of a child's readiness and eligibility for school, highlighting the importance of preventive health measures in educational settings.

Dos and Don'ts

When filling out the Florida Health form, especially for school entry, accuracy and attention to detail are crucial. Here are some important dos and don'ts to keep in mind:

  • Do thoroughly review the instructions on each section of the form to ensure you understand what is required.
  • Do fill out the form with recent and accurate information about your child's health and medical history to provide the school with a clear understanding of their needs.
  • Do explain any "Yes" answers in detail to give school health personnel a comprehensive view of your child’s health conditions and requirements.
  • Do ensure that the health care provider completes Part II of the form, including all necessary screenings and assessments, within one year of enrollment to comply with state laws.
  • Don't leave any sections blank. If a question does not apply to your child, indicate this with an "N/A" (not applicable) to show that you did not overlook the question.
  • Don't forget to sign and date the form, as your signature gives permission for school and health personnel to use the information to support your child's health and learning needs.
  • Don't withhold information about your child’s medical history or health conditions that could impact their education experience or require emergency action at school.
  • Don't ignore the recommendations for additional screenings and evaluations, such as the comprehensive vision examination, dental examination, and hearing screening, which can identify problems that may affect your child's ability to learn.

Misconceptions

Understanding the Florida Health Form that is required for school entry often brings up a range of questions and perhaps a few misconceptions. Here's a clear breakdown of some common misunderstandings:

  • Misconception 1: Every child entering school for the first time needs to complete the health form.
  • This is partially true. While the state law does require a health examination by a legally qualified professional for school entry, it's important to note that there may be additional or varying requirements determined by local school districts.

  • Misconception 2: Part I of the Health Form should be filled out by a healthcare provider.
  • Actually, Part I — Child’s Medical History is intended to be completed and signed by the parent or guardian. It asks for the child's general health status and medical history based on the parent’s or guardian's observations and knowledge.

  • Misconception 3: Information on the form is distributed widely for various purposes.
  • The information provided on this form is confidential and is reviewed and utilized only by the school staff and any school health personnel providing school health services in the district for the limited purpose of meeting the child's health and educational needs.

  • Misconception 4: Recommended services listed under the “Partnership for School Readiness” section are mandatory.
  • While these services, including comprehensive vision and dental examinations and a hearing screening, are highly recommended, they are not mandatory for school entry. They are suggested to ensure that any potential problems that could reduce a child’s ability to learn are identified and addressed as early as possible.

  • Misconception 5: The medical evaluation in Part II only assesses a child's current physical health condition.
  • Besides assessing the child's immediate physical health, Part II of the form also includes the healthcare provider's recommendations for participation in school activities, risks for TB, and any health conditions that may require emergency action at school. This comprehensive approach ensures that the child's school readiness is evaluated from multiple aspects, not just physical health.

It's crucial for parents and guardians to understand these key aspects of the Florida School Entry Health Exam form to ensure a smooth and informed process for their child's entry into school.

Key takeaways

Understanding how to correctly fill out and use the Florida School Entry Health Exam form is crucial for ensuring your child can seamlessly transition into their school environment. Below are six key takeaways that can help guide parents and guardians through this process:

  • It's a requirement. The state of Florida mandates a health examination for school entry, which must be completed by a legally qualified health care professional. This is a critical step in your child's school enrollment process.
  • Part I is for parents. Parents or guardians are required to fill out Part I of the form, which collects your child’s medical history. Make sure to check the appropriate boxes and provide explanations for any "Yes" answers, detailing your child’s medical conditions or concerns.
  • Accuracy is crucial. Providing accurate and comprehensive information about your child's health, including allergies, medications, and any past significant illnesses or surgeries, enables school health personnel to better address and accommodate your child's needs.
  • Communication with your child’s school is key. By signing the form, you’re not just providing necessary medical information but also consenting for school staff and health personnel to use this information to support your child’s health and educational experience. This partnership is essential for fostering a safe and nurturing school environment for your child.
  • Part II is for health care providers. This section must be completed by your child’s health care provider after conducting a thorough physical examination. It includes vital health metrics and screenings, such as vision and hearing tests, which are used to identify any conditions that may affect your child’s ability to learn and participate in school activities.
  • Additional screenings are recommended. While not required, it’s highly recommended that your child undergoes comprehensive vision, dental, and hearing screenings before starting school. These can help identify and mitigate potential barriers to learning, ensuring your child starts school ready to succeed.

By thoroughly following these guidelines and completing the Florida School Entry Health Exam form with attention to detail, parents and guardians can play a pivotal role in supporting their child’s health, well-being, and success in the school system.

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