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Stateof ConnecticutDepartmentof EducationHealthAssessmentecordTo Parentor Guardian:In order oprovidehebest ducationalxperience,chool ersonnel ustunderstandourchild'shealth eeds.his orm equestsnformatiofromyou(Part ) whichwill alsobe helpful o thehealth areproviderwhenhe or shecompleteshe medical valuationPart I).State aw requires omplete rimary mmunizations nd a healthassessmenty a legallyqualified ractitioner f medicine, n advancepracticeegisteredurse r registered urse, physician ssistantr theschool nedical dvisor rior o school ntrancen ConnecticutC.G.SSecs.10-204a nd 0-206).An immunization pdate nd additional ealthassessmentsre equiredn the 6th or 7th gradeand n the 9th orlOthgrade.Specific radeevelwill be determinedy the ocalboard f education. his orm rnayalsobe used br health ssessmentsequiredeveryyear br students articipating n sportseams.Student Name (Last D Male tr FemaleAddress (Street, own andZIP code)

Parent/Guardian Name (Lrst.First.Middle) HomePhoneSchool/Grade

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Part II - Medical EvaluationHealthCareProvidermustcomplete nd sign hemedicalevaluation ndStudentName Birth DateE I have eviewed he healthhistory nfbrmationprovided n Part of this fbrm

HAR-3 REV4/20physical examination

Date of Exam

PhysicalExamNote: xMandatedScreening/Testo be completed y providerunderConnecticutStateLaw*Height_in. l_Vo xWeight_lbs. l_0/o BMI_ l_% Pulse_ *BloodPressure_l_

Normal DescribeAbnormal Ortho Normal DescribeAbnormalNeurologicHEENT*GrossDentalLymphaticHeartLungsAbdomenGenitalia/ erniaSkin

TB: High-riskgroup'? U No O Yes PPDdatc ead:

*Postural D No spinalabnormality

Results:

U Spine bnormal i ty:tr Mild fl ModcrateD Marked f Ref'erralmad

Treatment:

ScreeningsVision ScreeningType: Right Lefi

With glasses 20l 20/Without glasses 201 201

D Referralmade

*Auditory ScreeningTvoe: Riuht Lef

U Pass Ll Pass-l Fail tr FailD Ret'erralmade

Lcad:Datc

*HCT/HGB:

Other:

* IMMUNIZATIONSD Up to Date or D Catch-upSchedule:MUST HAVE IMMUNIZATION RECORD ATTACHED*Chronic DiseaseAssessment:Asthma D No Q Yes: D Intermittent D Mild Persistent Ll ModeratePersistent .l SeverePersistent Ll Exercise nduceIJ'yes,pLease rovide a cop),- fthe Asthma Action Plan to SclutolAnaphylaxis O No D Yes: D Food D Insects fl Latex Ll UnknorvnsourceAllergies IJ yes,please pnnide a cop)' rf the Emergency Allergy Plan to Sclutr;lHistory f Anaphylaxis tr No fl YesDiabetes DNo EYes: DTypel t rTypeIISeizures tr No rl Yes.vpe:

Epi Pen equired -l No I YesOther Chronic Disease:

C ThissExplcrin:tudenthasa developmental, motional,behavioralor psychiatric ondition hat may affecthis or hereducational xperienc

Daily Medications specyJ'):This studentmay: tr participate fully in the schoolprogram

fl participate n the schoolprogramwith the following restrictioniadaptation:This studentmay: D participate fully in athletic activities and competitive sportsD participate n athleticactivitiesand competitivesportswith the following restriction/adaptation:tr Yes D No Basedon this comprehensive ealthhistory andphysicalexamination,his student asmaintained is/her evel of wellneIs this the student'smedicalhome? tr Yes D No D I rvould ike to discuss nformation n this report with the schoolnurse'

Signatureof health careprovider MD / DO / APRN PA Date Signed Printed/StampedProvider Name and PhoneNumbe

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HAR-3REV.4/2olmmunizationRecordTo the Health Care Provider: Pleasecompleteand initial below.Vaccine Month/Daylfear) Note: *Minimum requirements rior to schoolenrollment.At subsequent xams,note boostershotsonly

Dose Dose Dose Dose Dose5 DoseDTP/DTaPDT/TdTdapIPV/OPVMMRMeaslesRubellaHIB Students nderage 5HepAVaricellaPCV Pneumococcal onjugate accineHPVOtherFlu

DiseaseHxof above

KINDERGARTEN

GRADES .6

GRADES7.I2

(Specify) (Datc )Exemption

(Confirmedby)

Religious_ Medical: Permanent _ Temporary _ DateRecertifyDatc_ RccertityDate_ RecertityDate

Immunization Requirements for Newly Enrolled Students at Connecticut SchoolsDTaP:At least4 doses. he lastdosemust begiven on or afi er 4th birthdayPolio:At least doses. he astdosemustbe givcnon or aftcr4t h birthclayMMR: I doseon or after he lst birthdayMeasles:Second oseof measles accine or MMR). givcnat east weeks fier he lrstdoseHib: Children ess han 5 rs of ageneed doseat l2 rnonths r olclerChildren5 andolderdo not needproof of Hib vaccinationHep B: 3 dosesVaricella: doseon or after he I st birthday r veri l icat ion f diseascDTaP Td/Tdap:At least4 doses. he last dosemustbe givenon or after 4th birthdayStudentswho start he series t age7 or older only necda totalof 3 dosesPolio:At least doses. he astdosemustbe givenon or atter4t h birthdayMMR: I doseon or after he I st birthdayMeasles:Seconddoseof measles accine or MMR). siven at leastzl r.vecks fter he irst doseHep B: 3 dosesVaricella: doseon or after he I st birthdayor veri{icationof diseaseTd/Tdap:At least3 doses. he ast dosemustbe given on or after 4th birthday.Students .vho tart he series t age1 or olderonly needa total of 3 dosesPolio: At least3 doses. he lastdosemust be given on or after4th birthdayMMR: 1 doseon or after he lst birthdayMeasles:Seconddoseof measles accine or MMR), givenat least4 r.veeksfter he irst doseHe pB: 3 dosesVaricella:1 doseon or after {irstbirthdayor verificationof disease:VARICELLA VACCINE: For students I 3 yearsof age. 1 dosegiven on or after he lst birthday.For students 3 yearsofageor older,2 doses iven at east4 rveeksapartVERIFICATION OF DISEASE: Confirmation n writing by a MD, PA, or APRN that he child hasa previoushistory ofdisease, ased n family or medicalhistory

Initial/Signature of health care provider MD / Do / APRN pA Date Signed Printed/StampedProvider Name and Phone Number