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