Homepage Official Florida Health Template
Overview

The Florida Health Form, a vital document for children entering the school system, serves as a thorough check on a child's health and readiness for school. It is split into two main parts: the first part, completed by the parent or guardian, delves into the child's medical history, touching on aspects such as general health, allergies, medication use, sensory impairments (vision, hearing, speech), and any significant medical events like hospitalizations or surgeries. Explicit instructions urge parents to clarify any "Yes" answers, providing a detailed account of the child's health challenges that could impact their educational journey. The form's second section, reserved for healthcare professionals only, captures a complete physical examination, documenting vital statistics, screening results, and any medical conditions or necessities that could affect the child's school participation or require emergency attention. Additionally, the form suggests (but does not mandate) pre-kindergarten and kindergarten children undergo vision, dental, and hearing screenings to address potential learning barriers early on. This mandatory health evaluation underscores Florida's commitment to fostering an environment where children's health and educational needs are addressed comprehensively, enabling a smooth transition into the school setting.

Example - Florida Health Form

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

File Specifications

Fact Name Description
Form Identification The form is identified as DH3040-CHP-07/2013.
Purpose It is used for the School Entry Health Exam in the State of Florida.
Governing Law State law requires a health examination for school entry, conducted by a legally qualified professional.
Medical History Part I requests a child's medical history to be completed and signed by the parent or guardian.
Medical Evaluation Part II is to be completed and signed by a health care provider only.
Preventive Recommendations Recommendations include a comprehensive vision examination, dental examination, and hearing screening not required but recommended for prekindergarten and kindergarten readiness.
Screening Results Includes measurements such as height, weight, BMI, blood pressure, and screenings for vision, hearing, and dental health.
Health Conditions and Emergency Actions Information on any health condition that may require emergency action at school is collected.
School Activities Participation The health care provider indicates whether the child can participate fully or with restrictions in school activities.
Tuberculosis Risk Assessment Includes guidelines for TB risk assessment and instructions for healthcare providers on administering a Mantoux TB skin test.

Instructions on Filling in Florida Health

Once you've received the Florida Health school entry form, it marks the beginning of a process aimed at ensuring your child meets health requirements for school attendance. This procedure helps identify any health concerns that could affect your child's learning and school experience. Completing and submitting this form is a straightforward process. Following the steps below will guide you in providing the necessary information to comply with state laws and local school district requirements for your child's enrollment.

Completing the Florida School Entry Health Exam Form:
  1. Part I — Child’s Medical History:
    • Start by entering your child’s full name, birth date, sex, home address, the grade they are entering, city, ZIP code, and home telephone number.
    • Write your full name (parent/guardian) in the designated area.
    • Go through questions 1 to 8 regarding your child's health history. Check "Yes" or "No" for each question on the left column.
    • If you check "Yes" for any questions, provide explanations in the space given at the bottom of this section.
  2. Parent/Guardian Signature:
    • Read the consent statement at the end of Part I carefully.
    • Sign and date the form to give permission for school and health staff to review and utilize the information for your child's health and educational needs.
  3. Partnership for School Readiness Recommendations:
    • Notice the recommendations for additional health services like comprehensive vision and dental examinations, and a hearing screening. These are recommended but not required.
    • For each service, if completed, write down any corrective action taken, the date of the exam, the results, and the name of the health care provider.
  4. Part II — Medical Evaluation:
    • This section is for the health care provider only. Ensure you bring this form to your child's health examination.
    • The health care provider will fill out details about your child's physical exam, including screening results and any health conditions or recommendations for school activities.
    • Ensure the health care provider signs and dates the form, and provides their address and name printed or stamped.

After completing both parts of the form and gathering any additional reports or recommendations from the health care provider, you're ready to submit the form to your child's school. Ensure to keep a copy for your records. This form is a crucial step in preparing for a successful school entry by addressing any health concerns early on.

Understanding Florida Health

What is the purpose of the Florida Health Form for School Entry?

The Florida Health Form, officially known as the School Entry Health Exam form, is a crucial document designed to ensure that all children entering school in Florida are screened for potential health issues that could impact their ability to learn and participate in school activities. State law mandates this health examination be conducted by a legally qualified professional. The form facilitates communication between parents, healthcare providers, and school personnel about a child's general health, including any allergies, medications, past hospitalizations, surgeries, and significant illnesses or injuries. This process helps in identifying and managing any conditions that might affect a student's school performance or require special accommodations.

Who is required to fill out the Florida Health Form?

Part I of the Florida Health Form must be completed and signed by the parent or guardian of the child enrolling in school. This section gathers detailed information about the child’s medical history, including general health concerns, allergies, medications, and any past significant health events. Part II, the Medical Evaluation, is to be filled out and signed only by the health care provider who conducts the health examination. This part of the form reports on the physical findings, screening results, and any medical conditions or recommendations for the child’s activity participation at school.

What is the timeline for submitting the Florida Health Form?

The health examination must be completed within one year prior to enrollment in a Florida school. It's essential for parents or guardians to schedule this exam in a timely manner and submit the completed form to the school district before or at the time of their child's enrollment. Early planning and coordination with the child’s healthcare provider can help avoid delays in school entry.

Are there any additional health screenings recommended besides the mandatory health examination?

Yes, besides the required health examination, there are additional screenings recommended to further ensure a child's readiness for school, though these are not mandated by state law. These recommended screenings include a comprehensive vision examination for children aged 3 to 5, a comprehensive dental examination, and a hearing screening. The results from these examinations can provide valuable information to parents and educators about a child’s health needs that may affect learning, allowing for early intervention and support if necessary.

What happens if a child has a condition that may require emergency action at school?

If a child has a health condition that could necessitate emergency action while at school, such as allergies or seizures, it's critical that this information is clearly documented on the Florida Health Form. This enables school health personnel and staff to be prepared to respond appropriately to any health emergencies that may arise during school hours, ensuring the child’s safety and well-being.

How is the information on the Florida Health Form used by schools?

The information provided on the Florida Health Form is reviewed and utilized by school staff and health personnel providing school health services. It is used strictly for the limited purpose of meeting the child’s health and educational needs. This might include making necessary accommodations for the child’s full participation in school activities, managing any chronic health conditions at school, and facilitating communication between the school and parents regarding the child's health and safety. The form is stored confidentially in the child’s Cumulative Health Folder and accessed as needed to support the child’s success at school.

Common mistakes

Filling out the Florida Health form accurately is crucial for ensuring the well-being of children as they enter school. However, mistakes can sometimes occur. Identifying and avoiding these common errors can streamline the process, ensuring that all necessary information is correctly communicated. Below are eight common mistakes made when filling out the Florida Health form:

  1. Not providing detailed explanations for "Yes" answers in Part I — Child’s Medical History. Simply checking "Yes" without elaboration can lead to a lack of necessary insight into the child's health condition.

  2. Omitting the child's complete name and birth date at the top of the form. This information is essential for accurately identifying the student within the school system.

  3. Skipping the comprehensive details required for the vision, dental, and hearing screenings recommended for prekindergarten and kindergarten students. These screenings are critical for identifying issues that could impede the child's learning.

  4. Forgetting to sign and date the form, specifically the signature of the parent/guardian in Part I and the health care provider's signature in Part II. Signatures validate the information provided on the form.

  5. Leaving out the date of the health examination or reporting an exam date that is beyond the one-year requirement before enrollment. Timely health evaluations are mandatory.

  6. Failing to check or incorrectly checking the boxes related to the child’s participation in school activities and physical education due to health conditions. This information directly impacts the child's ability to engage in school activities safely.

  7. Incomplete reporting on vaccinations or TB risk assessment, particularly failing to mention a Mantoux TB skin test if applicable. This is especially relevant for children with certain risk factors for tuberculosis.

  8. Misreporting or omitting the child’s health conditions that may require emergency action at school. Accurate information on conditions such as allergies or seizures is crucial for ensuring the child's safety.

To prevent these common mistakes:

  • Thoroughly review each section of the form before starting, ensuring all required information is on hand.

  • Provide detailed explanations for any "Yes" responses, including specifying the type of allergies, medications, or conditions the child has.

  • Ensure that all screenings and assessments recommended for prekindergarten and kindergarten students are completed and accurately reported on the form.

  • Remember to include both the parent/guardian and health care provider’s signatures and dates to validate the form.

By avoiding these mistakes, parents and guardians can ensure a smoother, more accurate process for documenting their child's health status, ultimately supporting their safety and well-being as they enter the school environment.

Documents used along the form

When preparing for school enrollment in Florida, families are often met with the need to complete the State of Florida School Entry Health Exam form. This crucial document ensures that a child meets the health requirements mandated by state law for school attendance. Moreover, to provide a comprehensive overview of a child’s health and readiness for school, there are several other forms and documents that are commonly required or recommended to accompany the Florida Health Form. Understanding each of these additional documents can simplify the process for parents and guardians, making school entry smoother and more efficient.

  • Immunization Records: This document verifies that a child has received all required vaccinations according to the recommended schedule. It's essential for preventing the spread of infectious diseases within the school environment.
  • Birth Certificate: A copy of the child's birth certificate is often required for enrollment to verify the child's legal name, age, and citizenship or residency status.
  • Emergency Contact Information Form: This form contains details about who to contact in case of an emergency, including names, relationship to the student, phone numbers, and email addresses. It's vital for the school to have quick access to this information should the need arise.
  • Proof of Residency: Documents such as a utility bill, lease agreement, or mortgage statement help schools confirm that the child resides within the school district's boundaries.
  • Parental Consent and Release Form: This legal document allows the school to receive permission from parents or guardians for their child’s participation in school activities, including field trips, and to receive emergency medical care if necessary.

Completing and gathering these documents, along with the Florida Health Form, can appear daunting. However, they serve as critical tools in safeguarding children's wellbeing, ensuring they are ready and able to participate fully in the school experience. With careful preparation and attention to detail, families can navigate these requirements, ensuring their children embark on their educational journey equipped with the necessary health clearances and support.

Similar forms

  • The Immunization Record Form is similar to the Florida Health Form because both are essential for school enrollment, ensuring that children meet health requirements mandated by state law. These documents collectively verify a child’s health and immunization status, safeguarding not only their well-being but also that of their peers.

  • The Emergency Contact and Medical Information Form shares similarities with the Florida Health Form in that both provide crucial health information to school officials. This ensures prompt and appropriate responses to health emergencies by notifying school staff about allergies, medications, and specific health conditions a child has.

  • Consent for Treatment Form is akin to parts of the Florida Health Form, particularly where parental permission is granted for emergency treatment or review by health personnel. Both forms embody the proactive approach to health management in school settings, authorizing medical attention and interventions when necessary.

  • The Special Education Services Form, while focused on educational needs, parallels the Florida Health Form in its consideration of a child’s physical, social, and behavioral health in the educational context. Each form calls for a comprehensive review of the child's health and how it might affect learning, ensuring accommodations and support are in place for children with specific needs.

Dos and Don'ts

Filling out the Florida Health form for school entry requires careful attention to detail. Here's a guide to help parents and guardians navigate the process smoothly:

  • Do ensure to complete and sign Part I — Child’s Medical History. This section captures vital information about your child's general health and any conditions that might affect their school experience.
  • Don't rush through the questions related to health concerns, allergies, prescriptions, or past medical interventions. Your thoroughness in these sections can provide the school with the necessary insights to cater to your child’s needs effectively.
  • Do clearly explain any "Yes" answers in the space provided beneath the questions in Part I. Providing context to your child’s health concerns can assist school health personnel in offering the appropriate support.
  • Don't leave the explanation boxes blank if you've marked "Yes" to any concerns. Ambiguity in these sections may hinder the school's ability to provide optimal care and accommodations for your child.
  • Do remember to obtain and attach recommendations or required actions following the Partnership for School Readiness section, especially concerning vision, dental, and hearing screenings.
  • Don't forget to schedule the mentioned health screenings and assessments. These are crucial for identifying and addressing any conditions that may impact your child's learning ability before school starts.
  • Do have the health care provider complete Part II — MEDICAL EVALUATION. This section must be filled out by a legally qualified health care professional and provides a comprehensive overview of your child’s current health status.
  • Don't overlook the Tuberculosis (TB) risk assessment portion meant for the health care provider. Although you, the parent/guardian, won't fill this out, it's important to ensure it has been reviewed as part of your child's examination.
  • Do carefully review the completed form before submission, checking for any missed sections or inaccuracies that could delay your child's school entry process.

Following these guidelines can streamline the health form completion process, ensuring your child meets all the health requirements for school entry in Florida.

Misconceptions

There are several common misconceptions about the Florida Health form required for school entry. It's essential to clear these up to ensure parents and guardians understand how to properly complete the form for their child.

Misconception 1: This form is only for children entering school for the first time. This is not true. While primarily used for school entry, the Florida Health form may be requested again if there's a need to update a child's health records or when transferring to a new school district.

Misconception 2: All sections of the form must be completed by the parents. Actually, the form is divided into parts. Parents or guardians only need to complete Part I, which is about the child's medical history. A healthcare provider must complete Part II, which details the child's physical examination results.

Misconception 3: A child cannot attend school without this form being completely filled out. While it's true that state law requires a health exam for school entry, schools also understand that circumstances can delay this. Schools usually provide a grace period for submission, but it’s important to complete the form as soon as possible.

Misconception 4: The recommendations for additional screenings, like vision or dental exams, are optional and not important. While these are labeled as recommendations and not strict requirements, they are highly advised to address any issues that could impact the child's learning experience. Addressing vision, dental, or hearing problems early can significantly benefit a child's educational journey.

Misconception 5: The TB skin test results should be recorded on this form. The form explicitly states that any TB test or related information should not be recorded on it. The TB skin test is part of the health examination but is handled confidentially and separately.

Misconception 6: Parents must fill out and explain every "Yes" answer in Part I in detail on the form itself. While it's crucial to disclose any health concerns or conditions, detailed explanations are not always required to be written directly on the form. Instead, discussions can be held with school health personnel to ensure any necessary accommodations are made.

Understanding these key points about the Florida Health form can help streamline the process of preparing for the school year, ensuring that all children have their health needs appropriately addressed as they start or continue their educational journey.

Key takeaways

Filling out the Florida Health form correctly and comprehensively is crucial for ensuring your child meets all the necessary health requirements for school entry. The form requires detailed information about your child's health history and a recent health examination. Here are five key takeaways to keep in mind:

  • Complete Part I carefully: This section must be filled out by the parent or guardian. It gathers essential information about the child's medical history, including allergies, medications, and any past hospitalizations or surgeries. Ensuring accuracy in this part of the form can help school health personnel provide the best care for your child.
  • Understand the necessity of a health examination: State law mandates that a health examination be conducted by a legally qualified professional within one year of enrollment. This part of the process is critical for identifying any health issues that could affect your child's educational experience.
  • Gather and report vision, hearing, and dental screenings: While not required, it's highly recommended to obtain comprehensive vision, dental examinations, and hearing screenings for your child. These screenings can uncover issues that may hinder your child's learning, allowing for early intervention.
  • Permission to utilize health information: By signing the form, you give permission for school staff and health personnel to review and use the health information you've provided. This enables them to support your child's health and educational needs effectively. Be assured that this information is used with your child’s best interest in mind.
  • Address potential health conditions thoroughly: If your child has a health condition that may require emergency action at school (e.g., allergies, seizures), it’s crucial to specify this on the form. This ensures that school personnel are prepared to respond appropriately to your child's needs.

By paying close attention to the details and requirements outlined in the Florida Health form, you can help pave the way for a smoother, safer school entry process for your child. Remember, this form plays a significant role in ensuring that your child receives the appropriate support and accommodations necessary for a successful school experience.

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