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The Florida Health Form plays a critical role in ensuring that children meet necessary health standards as they enter school. This form is not merely a bureaucratic requirement; it is a tool designed to protect the health and well-being of students. Parents or guardians must complete Part I, which details the child’s medical history. This section asks for information regarding general health concerns, allergies, prescribed medications, and any notable illnesses, injuries, or disabilities. Parents are also given the opportunity to share additional insights about their child's health needs. Following this, Part II must be filled out by a licensed health care provider, offering a comprehensive medical evaluation that includes vital statistics such as height, weight, and BMI, as well as screening results for vision, hearing, and dental health. Furthermore, it highlights any existing health conditions that may impact the child’s educational experience, ensuring that school personnel are aware of any potential emergencies or accommodations necessary for the child’s learning environment. Lastly, the form emphasizes collaborative support, encouraging parents to work with healthcare providers to address concerns that could hinder their child’s academic success. Such thorough information collection is designed to foster a safe and healthy school setting for every child.

Florida Health Example

Page 1 of 2

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

Get Florida Health PDF Form

Form Characteristics

Fact Name Description
Purpose The Florida Health Form is required for school entry to ensure that children receive necessary health examinations.
Governing Law According to Florida Statute § 1003.22, parents must provide proof of a health examination for their children before enrollment.
Medical History Part I of the form collects medical history from the parent or guardian, addressing concerns such as allergies and previous illnesses.
Health Care Provider A licensed health care provider must complete Part II, which includes a full physical exam of the child.
Screening Requirements The form includes screenings for vision, hearing, and dental health, which help identify potential barriers to learning.
Emergency Health Conditions Parents must report any health conditions that may require emergency action, ensuring the child’s safety at school.
Confidentiality Information collected on this form is confidential and will be used solely for educational and health purposes by school personnel.

Guidelines on Utilizing Florida Health

Completing the Florida Health form is important for your child's school entry. The information gathered will help school staff understand your child’s health needs. Below are the steps to fill out the form accurately.

  1. Start with Part I — Child's Medical History. Print your child's full name, birth date, and address at the top of the form.
  2. Fill in the parent/guardian's full name and home telephone number.
  3. For questions 1 through 8 in Part I, check "Yes" or "No" for each item, indicating any health concerns. If you answer "Yes" to any question, provide further details in the space provided.
  4. Sign under the statement indicating permission for staff to use the information to support your child's educational needs.
  5. For Part II — Medical Evaluation, wait for a licensed health care provider to complete this section. They will record the date of your child’s physical exam and exam results.
  6. Ensure the health care provider fills in screening results, including height, weight, vision, and hearing tests as applicable.
  7. If there are any recommendations for your child’s school activities, the health care provider must specify these on the form.
  8. Finally, check that both you and the health care provider have signed and dated the form where required.

What You Should Know About This Form

What is the purpose of the Florida Health form?

The Florida Health form is designed to gather essential health information about a child before they enter school. This information helps to ensure that schools can provide appropriate health services and accommodations for each student's individual needs. It is a requirement by state law for children entering school to undergo a health examination by a qualified professional. Parents or guardians need to complete the form accurately to facilitate this process.

What information do I need to provide about my child's medical history?

In Part I of the form, parents or guardians are required to answer a series of questions concerning the child's general health, allergies, specific illnesses, and behavioral issues, among others. There is a space to explain any affirmative answers, providing additional context if necessary. This detailed medical history is important for the school's health personnel to understand any health concerns that could affect the child's learning or participation in school activities.

What happens if I answer "yes" to any of the medical history questions?

If you answer "yes" to any of the questions regarding your child's medical history, you should provide explanations in the designated area. This additional information will help school health personnel understand the situation better and potentially take necessary actions to support your child's health and educational needs. It is vital to communicate any significant health issues or concerns so the school can provide suitable accommodations or interventions.

Is a health examination required for all children?

Yes, a health examination is a state requirement for all children entering school in Florida. The examination must be carried out by a qualified health care provider within one year prior to enrollment. This ensures that the child is in good health and able to participate in school activities, including physical education.

What should I do if my child has specific health conditions?

For children with specific health conditions that may impact their educational experience, the health care provider will document these conditions on the form. It is essential to communicate any health issues that could pose a risk during school activities, such as allergies or conditions requiring emergency action. Providing accurate information will help the school develop plans to support your child's health and safety needs while at school.

Common mistakes

Completing the Florida Health form accurately is crucial for your child’s school entry. Many parents make common mistakes that can lead to delays or issues in processing. One significant error occurs when details about the child’s medical history are not fully or clearly filled out. This section requires attention to detail. Leaving it incomplete can raise questions about your child’s health and eligibility for school services.

Another mistake often made involves failing to provide explanations for any “Yes” answers in the medical history section. If you check “Yes” for any health concerns, you are required to elaborate. Omitting these explanations might prevent the school from understanding your child’s needs, which could impact their care while at school.

Listing the child's name incorrectly or not including the full name can also lead to complications. Ensuring the name is filled in as per official records is essential to avoid any mismatches that may arise later, especially when dealing with health records.

Many parents forget to provide the required signature on the form. This signature is not just a formality; it confirms that you, as the parent or guardian, acknowledge and permit the information provided to be used for your child's health and educational needs. Incomplete signatures might render the form invalid.

Additionally, a frequent oversight is the neglect of including updated contact information and emergency contacts. This information is vital, as it ensures the school can reach you or someone in case of an emergency regarding your child's health.

Finally, the submission of the health form without an updated medical evaluation can prevent your child from entering school. A current physical exam, conducted within the last year, is a requirement. Ensure your health care provider completes and signs this section appropriately for smooth school enrollment.

Documents used along the form

The Florida Health form is an essential document for parents or guardians as they prepare their child for school entry. However, several other forms and documents are often required or recommended in conjunction with the Florida Health form to ensure comprehensive health assessments and support for your child's educational experience. Below is a list of these documents along with brief descriptions.

  • Immunization Record: This document provides a detailed account of all vaccinations the child has received. It is critical to verify that the child is up-to-date on required immunizations before enrollment.
  • Emergency Contact Form: This form contains important information about whom to contact in case of an emergency involving the child, providing peace of mind for parents and school officials alike.
  • Vision Screening Report: This report details the findings from a vision screening conducted by a qualified professional. It helps identify potential vision issues that could impact learning.
  • Dental Health Report: Similar to the vision screening report, this document outlines the results of a dental examination. It highlights any necessary follow-up care and promotes oral health among students.
  • Hearing Screening Report: This report presents the results of a hearing test. Addressing hearing issues early can significantly influence a child's learning and social interactions.
  • Asthma Action Plan: If the child has asthma, this plan outlines the necessary steps for managing their condition at school. It includes information on medications and triggers to help school staff respond appropriately.
  • Allergy Action Plan: For children with allergies, this document details allergens, symptoms of reactions, and emergency procedures. It ensures that school personnel are prepared to respond effectively.
  • Physical Examination Report: Conducted by a medical professional, this report summarizes health evaluations and indicates if the child can participate fully in school activities.
  • Student Health History Form: This comprehensive form gathers information about the child's health history. It assists healthcare providers in ensuring that the child receives appropriate care and accommodations.

These forms collectively create a thorough picture of a child's health needs, thus fostering a safe and supportive educational environment. Completing these documents accurately and thoroughly will help ensure that your child is well-prepared for a successful school experience.

Similar forms

The Florida Health form for school entry serves an important role in ensuring that a child is medically prepared to participate in school activities. Other documents share similar purposes, often focusing on health assessments, parental approval, or education-related health information. Below is a list of eight documents that are comparable to the Florida Health form, along with their similarities:

  • School Health Records: Like the Florida Health form, these records track students' health histories and treatment plans, allowing school nurses and personnel to provide appropriate care.
  • Immunization Records: Immunization forms require parents to list vaccinations received. Both documents aim to ensure a child's health and safety before entering a school environment.
  • Physical Examination Forms: These forms document the results of a child's physical exam, similar to the evaluation part of the Florida Health form, ensuring children are fit to engage in schooling.
  • Permission Slips for School Activities: Just as the Florida Health form requires parental consent for health information sharing, these slips ask for permission for participation in school outings or activities.
  • School District Health Guidelines: These guidelines outline health and safety protocols. They, like the Florida Health form, focus on maintaining the welfare of students during school hours.
  • Emergency Contact Forms: These forms provide crucial contact information in case of a health crisis, similar to the section of the Florida Health form that addresses emergency health issues.
  • Special Needs Documentation: This documentation identifies children with special health considerations, thereby guiding how schools can best support those students, akin to the specific health requirements noted in the Florida Health form.
  • Health Condition Action Plans: These personalized plans outline how to manage chronic health issues within school settings, similar to the recommendations and emergency information on the Florida Health form.

Each of these documents plays a significant role in promoting student health and safety within the educational system. Their goals often intersect, ensuring that children can access educational opportunities while receiving necessary health care and support.

Dos and Don'ts

When filling out the Florida Health form, there are several best practices to keep in mind. Here is a list of ten tips that can help ensure the process goes smoothly:

  • Do read the instructions carefully before you begin filling out the form.
  • Do use clear and legible handwriting when filling in your child's information.
  • Do review the medical history questions thoroughly and check all that apply.
  • Do provide detailed explanations for any "Yes" answers to help school health staff understand your child’s needs.
  • Do ensure that all required sections of the form are completed before submission.
  • Don’t leave any mandatory fields blank; this could delay processing.
  • Don’t use abbreviations or unclear terms when explaining medical history.
  • Don’t forget to sign and date the form, as this is critical for validation.
  • Don’t include unnecessary personal or medical information that is not asked for in the form.
  • Don’t hesitate to ask for help if you're unsure about how to fill out any part of the form.

Each of these tips can help support your child’s health evaluation process and ensure they receive the best care possible at school.

Misconceptions

  • Misconception 1: Parents can opt out of the health examination requirement.

    • Many parents believe that they have the choice to skip the health examination. However, Florida state law mandates that a health exam by a qualified professional is necessary for school entry.

  • Misconception 2: The health form only needs to be filled out if there are existing health issues.

    • Some think the form is applicable only when there are known health concerns. In reality, the form serves as a comprehensive record of the child's health, regardless of whether issues have been diagnosed.

  • Misconception 3: Completing the form is purely a formality.

    • While the form may seem like just paperwork, the information gathered can genuinely impact a child’s educational experience. It informs school health personnel about the child's needs and helps ensure a supportive environment.

  • Misconception 4: The parent or guardian’s information is not confidential.

    • Parents may worry that their information will be shared widely. However, the details provided are used solely for school health purposes and are kept secure according to regulations.

  • Misconception 5: The health examination has to be done by a specific type of doctor.

    • Some believe that only pediatricians can conduct the examination. In fact, the law allows any legally qualified health professional to perform the health exam, broadening the options for families.

  • Misconception 6: The form must be completed by the time of school registration.

    • While it is important to complete the form soon, there is a window of time to submit it. This grace period provides parents with the opportunity to gather the required health information at their convenience.

  • Misconception 7: The medical evaluation section is solely for the physician's use.

    • This section not only aids health care providers but also informs school staff about any conditions that may affect the child in an educational setting.

  • Misconception 8: There are no follow-up requirements after submitting the form.

    • Some parents think that after submission, no further action is needed. In reality, if any questions indicate health concerns, follow-ups may be necessary to ensure the child receives appropriate support in school.

Key takeaways

  • Complete Part I: Child's Medical History - Parents or guardians must fill out this section thoroughly, reflecting on any health concerns their child may have.
  • Be Honest about Health Issues - If there are any “Yes” answers on the form, providing an explanation is essential for accurate understanding.
  • Provide Correct Contact Information - Ensure that all contact information, including telephone numbers, is up to date for quick communication regarding your child's health.
  • Consult Health Care Providers - Parents are encouraged to work with medical professionals to address any health issues that could affect their child’s learning.
  • Follow Up with Exams and Screenings - Comprehensive exams for vision, dental health, and hearing are recommended, especially for younger children entering school.
  • Health Evaluation by a Qualified Professional - A licensed health care provider must complete Part II of the form, confirming a physical exam took place within the past year.
  • Information is Confidential - The submitted health information is intended solely for authorized school personnel and supports your child’s educational needs.
  • Discuss Emergency Health Conditions - If your child has health issues that may require immediate attention, clearly specify these conditions on the form.

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