River Vale School District by mikeholy

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									                                 RIVER VALE SCHOOL DISTRICT
                                     CHILD STUDY TEAM
                            PRE-K HEALTH HISTORY AND ASSESSMENT

DATE:

I. STUDENT PROFILE:
    Child’s Name: ____________________________________                          Date of Birth: _________________
    Age: ________       Height__________            Weight_________            Sex:         M           F
    Mother’s Name:                                                   Father’s Name:
    Siblings Name:                                                   Age: _________________
                                                                     Age: _________________

II. REASON FOR REFERRAL:                                 (Referred by :______________________________)
    Primary area of concern:
        Expressive language
        Receptive language
        Social skills development
        Behavior difficulties
        Other:


    Secondary area of concern:
    Explain:



III. HEALTH PROBLEMS:             (List and describe any health problems and their management/treatment.)




IV. MEDICAL HISTORY:              (List with dates and age)
         Hospitalization    (include reason, overnight stay, emergency room visit, outpatient, same day surgery)


         Illness (include contagious disease, high fever, etc.)


         Injuries (accidents, ingestions, head injury, etc.)




Page 1                                                                                                  Pre-K Health Assessment
                                                                                                                           03/06
IV. MEDICAL HISTORY (CONTINUED):                         (List with dates and age)
             Medications (include name and dosage)


            Allergies


         Date of last health care visit:__________________ Name of Provider:

         Purpose of visit:_____________________________________________________________________

         Dental Care: Has child seen dentist?               No              Yes           Date:

V. BIRTH AND DEVELOPMENTAL HISTORY:
    1. Birth weight: _____pounds______ounces
    2. Gestation (Duration of Pregnancy) _________weeks or ________months
    3. Pregnancy: Maternal age:_________                  # of pregnancies_________
    4. Habits during pregnancy: (circle if applicable) smoking, drinking, drugs, other (Please explain):

    5. High risks: (circle) infections, bleeding, high blood pressure, anemia, fever, RH factor,
          trauma, inherited disease, medications, excessive weight gain, chronic disease, diabetes, hospitalization,
          other (Please explain):
    6. Labor and Delivery problems?                  None            Yes: (Please explain):
          ________________________________________________________________________________
    7. Neonatal problems: (circle) Breathing, infections, RH factor, jaundice, transfusions, bleeding,
       congenital anomaly, feeding, other: (Please explain)
       ________________________________________________________________________________
    8. Development: (Please state age if known)
          Sat alone:                                        First words:
          Crawled:                                          Spoke in sentences:
          Stood:                                            Toilet trained:
          Walked alone:                                     Other:

          Coordination difficulty:             No            Yes (Please explain)
          (E.g., fine motor, large muscle, other areas of concern)
          ________________________________________________________________________________

          Is development         faster,     slower or       equal to siblings or peers?

          Comments:




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                                                                                                                     03/06
VI. FAMILY HEALTH HISTORY:
    Please check any applicable familial diseases:
       heart disease         stroke             hypertension            diabetes            asthma
       allergy               anemia             sickle cell disease or trait                arthritis
       cancer                epilepsy           cataracts                glaucoma           kidney disease
       tuberculosis          learning disabilities (please explain):
    _______________________________________________________________________________________
    _______________________________________________________________________________________
VII. HABITS:
            Thumb sucking              Other:
            Nightmares                 Other:
            Sleepwalking
            Rocking
VIII. REVIEW OF SYSTEMS:
         1. General: Changes in weight, appetite, activity level, bowel habits, resistance to disease. Explain:


         2. Birth Defects: Congenital anomalies. Explain:

         3. Skin: Rashes, easy bruising, changes in skin color or texture, eczema, impetigo, growths, or tumors.
            Explain:

         4. Head: Headache, trauma, infections. Explain:

         5. Eyes: Vision changes, trauma, infections, cataracts, glaucoma, other Explain:

         6. Ear, Nose, Throat: Infections (specify), trauma, epistaxis, allergies, hearing changes, voice changes,
            caries, and speech problems. Explain:

         7. Neck: Trauma, swollen lymph nodes, limitation of movement. Explain:

         8. Respiratory: Infections, breathing problems, trauma, wheezing, cough, asthma. Explain:


         9. Cardiovascular: Murmur, fatigue with exertion, cyanosis. Explain:

         10. Gastrointestinal: Abdominal pain, nausea, jaundice, vomiting, diarrhea, constipation, ulcer. Explain:

         11. Genitourinary: Infections, enuresis, encopresis, discharge, rashes, menstruation, sexual
             development. Explain:


Page 3                                                                                        Pre-K Health Assessment
                                                                                                                 03/06
VIII. REVIEW OF SYSTEMS (CONTINUED):
         12. Musculosketal: Trauma, limitation of movement, joint pain or swelling, growths or tumor, curvature
             of the spine, braces, corrective shoes. Explain:

         13. Neurological: Birth injury, trauma, seizures (febrile vs afebrile) staring speels, poor coordination or
             balance, dizziness, syncope, developmental evaluation. Explain:

         14. Endocrine: Increased thirst, appetite, urination, diabetes, thyroid problems. Explain:

         15. Hemotologic: Anemia, blood transfusions, blood dyscrasias, sickle cell. Explain:

         16. Psychosocial: Changes in activity level, behavior, relationships, punishment, rewards. Explain:

         17. Nutrition: (24 hour recall including snacks):


IX. VISION SCREENING:
         Has the child visited an eye doctor?      No                 Yes Date of visit:
         Comments:
         Does the child wear glasses?:      No               Yes      Date started wearing glasses:
                                            Left                   Right           Both

            Without Correction:          WO 20/              WO 20/            WO 20/
            With Correction:             W 20/               W 20/             W 20/

X. HEARING SCREENING:
    Has the child had frequent ear infections?          No            Yes      How often?
            Threshold Test on:
                        500               1000           2000               3000            4000
             Right

              Left

    Comments:


    How was the child’s behavior during the Vision and Hearing Screenings (e.g., restless, cooperative, crying,
    etc.) Explain:
Completed by:



Mrs. JoAnn Hirsch, R.N., M.S.N.                                                            Date
Certified School Nurse
Page 4                                                                                             Pre-K Health Assessment
                                                                                                                      03/06

								
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