GENERAL HEALTH APPRAISAL FORM PARENT please complete AND SIGN Child’s Name:_______________________________________________________ Birthdate: _____________________ Allergies: ‰ None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________
Diet: ‰ Breast Fed ‰ Formula _______________________ ‰Age Appropriate
‰Special Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
‰ Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding. I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care or camp personnel. FAX #: _____________________________ DATE: _____________________________ Parent/Guardian Signature___________________________________________________________________ HEALTH CARE PROVIDER: Please Complete After Parent Section Completed Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________ Physical Exam: ‰ Normal ‰ Abnormal (Specify any physical abnormalities)_____________________________________________________ Allergies: ‰ None or Describe__________________________ Type of Reaction __________________________________________________ 6LJQLÀFDQW+HDOWK&RQFHUQV ‰Severe Allergies ‰Reactive Airway Disease ‰Asthma ‰Seizures ‰Diabetes ‰Hospitalizations
‰Developmental Delays ‰Behavior Concerns ‰Vision ‰Hearing ‰Dental ‰Nutrition ‰ Other ________________________________
Explain above concern (if necessary, include instructions to care providers): ______________________________________________________
Current Medications/Special Diet: ‰ None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp
For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
‰Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
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OR ‰Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
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Immunizations: ‰Up-to-Date ‰ See attached immunization record ‰Administered today: _____________________________________________ Health Care Provider: Complete if Appropriate **ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE** ** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ ** ** HCT/HGB _____ ** Lead Level ‰Not at risk or Level _____ **TB ‰Not at risk or Test Results ‰ Normal ‰ Abnormal **Screenings Performed: ‰Vision: ‰Normal ‰Abnormal ‰Hearing: ‰Normal ‰Abnormal ‰Dental: ‰Normal ‰Abnormal- Recommended Follow-up________________________________________________________________________________________ Provider Signature 2IÀFH6WDPS
Next Well Visit: ‰ Per AAP guidelines* or ‰ Age__________
This child is healthy and may participate in all routine activities in school sports, child care or camp SURJUDP$Q\FRQFHUQVRUH[FHSWLRQVDUHLGHQWLÀHGRQWKLVIRUP
_____________________________________________________
Signature of Health Care Provider (certifying form was reviewed) Date: _______________
The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years. Copyright 2007 Colorado Chapter of the American Academy of Pediatrics
STABILIZED FOLIC ACID VITAMIN FOR THE REDUCTION OF EXCESS SLUDGE IN SEWAGE TREATMENT PLANTS Jörg Strunkheide, Dr. Ing. (Sankt Augustin, Germany) Folic acid sources and medical application Vitamins are essential nutritional compounds that contribute to a variety of functions, includingmetabolic maintenance and cell growth /1/. Each vitamin has particular roles that cannot befulfilled b
GORHAM SCHOOL DEPARTMENT ALLERGY PROTOCOL HEALTH SERVICES STAFF DEVELOPMENT 1. Prior to the beginning of the school year, all staff, including food service, transportation, custodial, and maintenance staff will be trained by the school nurse about the following topics: • OSHA standard for blood borne pathogens • General first aid procedures • Emergency cards, confidentiality â