Shelby County Schools



DAILY HEALTH CHECK FORM

Child’s Name _______________________________ Date __________________

Teacher/ Teacher Assistant _____________________________________________________

Instructions for Completion: Please assess all areas of health on each child daily upon arrival. Only document those areas that require further evaluation or follow up by making a note in the appropriate box on this form. Place in the child’s file. A blank copy of this form should be posted in your classroom along with procedure H3 Daily Child Health Checks.

Note: As an extra precautionary measure, children’s pockets, backpacks, coats, etc. must be checked to ensure that they are free of inappropriate items, i.e., coins, small toys, any items hazardous to a child’s safety or health.

|1. Eyes |(1a) Pink |(1b) Rubbing |

|(1C) Red |(1d) Swollen |(1e)Running |

|2.Ear |(2a) Discharge | |

|3. Skin |(3a) Rash |(3b) Bumps/Insect Bites |

|(3c)Bite Marks |(3d)Whelps |(3e) Scratches |

|4.Sharp Objects in Pockets, Backpacks or Coat/Jacket |

|5.Nose |(5a) Running |(5b)Sniffles |

|6. Vomiting |

|7. Drowsy or Sleepy |

|8. Fingers/Nails |(8a)Cut |(8b)Burn |

| |(8c) Sore | |

|9. Lips |(9a) Busted |(9b) Cold Sore |

|10. Arm |(10a)Sore |(10b) Cut |

|11. Face |(11a)Scratch |(11b)Bump |

|12. Cut |(12a)Face |(12b)Head |

|(12c) Eye |(12d) Ear | |

|13. Bruise |

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