CHAPTER 8 - BCSD Static Server - Bakersfield City School District

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Initial Health History (form HS 9) Health History and Nursing Assessment for Special Education Process and Forms This form is to be utilized for all initial Search and Serve referrals, Speech only assessments, RSP initial assessments, and SDC initial assessments where no known health condition exists. The nurse is to review this form, sign, date and make pertinent comments such as “no indication of health concerns”. If there is an indication of health concerns then a more indepth assessment must be completed and follow-up documented. Health History Update (form HS 10) This form is to be utilized for all Speech only tri-annual, RSP tri-annual, and SDC triannuals where no known health conditions exists. The nurse is to review this form, sign, date and make pertinent comments such as “no indication of health concerns”. If there is an indication of health concerns or changes since previous health assessment then a more in-depth assessment must be completed and followup documented. Nursing Assessment (form NA-2) This form is to be utilized for those students for whom the need for a more in-depth nursing assessment is indicated on the health history form in the mild/moderate program and who have non-complex medical concerns. This form may also be utilized for tri-annual updated nursing assessments for all students. Nursing Assessment (form NA-1) This form is to be utilized for initial assessment on all students with a determination of severely handicapped or who have a complex medical condition. This form is also to be completed on all Early Start initial referrals in addition to the IFSP form. Nursing Summary (form NA-3) This form is to be utilized for those students who need updates do to changes in status prior to a three year re-assessment. It can also be utilized for tri-annual for all students with noncomplex medical concerns such as on-going treatment for head lice, asthma, etc. Health Summary (Form HS-82) This form can be utilized for those students who need updates due to changes in status prior to a three year re-assessment. It can also be utilized for tri-annual for all students with noncomplex medical concerns such as on going treatment for head lice, asthma, etc. 10
BAKERSFIELD CITY SCHOOL DISTRICT HEALTH SERVICES – 714 Williams Street <strong>Bakersfield</strong>, CA 93305- (661) 631-5895 Date <strong>School</strong> Grade Teacher INITIAL HEALTH HISTORY SID #: Pupil’s Social Security #: - - Pupil’s Name Sex Birthdate Age Parents: Father In Home Yes No Mother In Home Yes No Address Guardian/Other Name of Person Completing Form Phone Relationship Relationship Physician Address Phone # Dentist Address Phone # Current Medication (Indicate name and how often given) Known Allergies Is child a Client of: MediCal SSI CCS KRC Vision Tested: Results Hearing Tested Results PLEASE CHECK THE APPROPRIATE ANSWER IN THE FOLLOWING SECTIONS AND EXPLAIN ‘YES’ ANSWER UNDER COMMENTS PREGNANCY HISTORY (With this child) Mother’s age Received Medical care Yes No (at time of pregnancy) Yes No Used tobacco – How much Yes No Infections Yes No Consumed alcohol – How much Yes No Previous miscarriage Yes No Medicines Yes No Maternal diabetes Yes No Used recreational drugs – How much Yes No Pregnancy planned Yes No Weight gain more than 30 lbs. Yes No Mother illness or injury while pregnant Yes No High blood pressure Yes No Child # 1 2 3 4 5 6 or Yes No Length of pregnancy Yes No Other conditions/Illness DELIVERY HISTORY (with this child) Yes No Water broke too early / Premature rupture of membranes Yes No Normal delivery Yes No Cord around baby’s neck Yes No Forceps Yes No Mother asleep / General anesthetic Yes No Did baby cry right away Yes No Cesarean section (circle: Planned / Unplanned) Yes No Did baby breathe right away Yes No Any observed skull damage at birth Yes No RH incompatibility Yes No Oxygen given Yes No Fetal distress NEWBORN HISTORY (first month of this child’s life) Birth weight Age of baby when he/she came home from hospital Yes No Baby had yellow jaundice Yes No Vomiting Yes No Blueness of skin Yes No Diarrhea Yes No Seizures (convulsions) Yes No Infections Yes No Sleep problems Yes No Feeding problems Yes No Other Illnesses Yes No Other problems ILLNESSES (Please give approximate age of illness or injury) Yes No Age Skin infection Yes No Age Diabetes with medication Yes No Age Unconscious more than 1 hour Yes No Age Anemia Yes No Age Hayfever / Allergies Yes No Age Tumor or growth Yes No Age Hospitalization for Yes No Age Accidental poisoning Yes No Age Asthma Yes No Age Other Illnesses HS 9 FF Rev 7-06 11
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CHAPTER 8 - BCSD Static Server - Bakersfield City School District

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