School Health Screening

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School Health Screening Form

Complete all applicable sections

🔗 Link to existing student:

🔍 Search by Hospital #:

👤 Demographics

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Screen Date *

Hospital No *

⚠️ Must be unique. Use 000000 if no hospital number is available.

First Name

Middle Name

Last Name

Sex

Date of Birth *

Age ● AUTO

Citizenship

If other citizenship

Ethnicity

Race

Religion

If other religion

State

Hamlet

School

Grade

Parent/Guardian Last Name

Parent/Guardian First Name

Home Phone

Mobile Phone

Children with Special Health Care Needs (CSHCN)

Child has a disability or special health care need (CSHCN)

📏 Physical Assessment

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⚡ Auto-Calculated Fields: Age is computed from DOB. BMI, BMI percentile & category use CDC BMI-for-age charts (requires sex & DOB). BP category follows AAP 2017 pediatric guidelines (age-specific for children <13, adult thresholds for ≥13).

Height (Inches) *

Weight (Lbs) *

BMI ● AUTO

BMI% ● AUTO

BMI Category ● AUTO

Waist

BP Systolic *

BP Diastolic *

PR/RR

BP Category ● AUTO

Vision SC Right

Vision SC Left

Vision CC Right

Vision CC Left

Vision (Left)

Vision (Right)

Protein

Occult Blood

Glucose

Referral Needed (Physical)

How do you feel about your health?

🩺 Physical Examination

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General Appearance

Nutritional Status

General Comments

HEENT

Cardiovascular

Respiratory

Neurological

Skin & Integumentary

Musculoskeletal

Edema Assessment

Summary of Clinical Findings

Primary Diagnosis ICD-10

Secondary Diagnosis ICD-10

Tertiary Diagnosis ICD-10

Taking Medications

Medical Conditions

Asthma

Seizures/Epilepsy

Diabetes

Heart Condition

ADHD

Autism Spectrum

Anxiety

Depression

Family / Medical History

Illness History

If yes, describe

Family History

If yes, describe

Social History

If yes, describe

Allergies History

If yes, describe

Anyone at home uses tobacco, alcohol, marijuana, or other drugs?

Recommended Immunization History

HPV Vaccination (Human Papillomavirus)

1st Dose 2nd Dose Not vaccinated Unknown

🥗 Diet / Nutrition

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Servings of fruit per day

Servings of vegetables per day

Sugary beverages frequency

Cups of water per day

Meals eaten yesterday (check all)

Breakfast Lunch Dinner Snacks

Local Food Consumption (Past Week)

Fresh fish or seafood

Taro, tapioca, breadfruit

Local green vegetables

Local fresh fruits

Eat at school cafeteria

Buy food from stores/vendors near school

Education & Counseling Provided (Diet)

Portion sizes and serving recommendations Healthy beverage choices Reading nutrition labels Cultural food preservation Benefits of traditional/local foods Importance of regular meals Healthy snack options

🏃 Physical Activity

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Days physically active (≥60 min) in past week

Aerobic Activities (check all)

Muscle/Bone Strengthening (check all)

Climbing trees/equipment Push-ups/sit-ups Traditional activities Martial arts/boxing Weightlifting/gym None

Screen Time (Typical School Day)

Watching TV

Phone/Tablet/Computer

Playing Video Games

Total Screen Time (hrs)

PE class days per week

How get to school

Sleep hours (school nights)

Barriers to physical activity

No safe places Too much homework Weather No equipment Family unsupportive Transportation Other

👂 Hearing Screening

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Right Tympanometry

Left Tympanometry

Ear infections/tubes history

Right OAE (Grades 1–3 only)

Left OAE (Grades 1–3 only)

Referral Needed (Hearing)

🦷 Oral Health

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Visual Inspection

Dental Sealant Present

Last Dental Visit

Obvious Dental Issues

Dental Hygiene Habits

Brushes 2x daily Flosses regularly Irregular/concerning

Oral Hygiene Status

# of Dental Caries

Dental Treatment Summary

Tooth Numbers

Missing teeth

Teeth with caries

Teeth requiring extraction

Teeth requiring fillings

Teeth requiring sealants

Teeth with existing sealants

Dental Age Assessment

Fluoride Varnish

Dental Referral Status

🛡️ Adverse Childhood Experiences

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Physical Abuse Screening

Hurt by someone in family?

Hit/kicked leaving marks?

Afraid of anyone at home/school?

Sexual Abuse Screening

Has anyone touched your private parts when you didn't want them to?

Has anyone asked you to touch or look at their private parts?

Has anyone shown you pictures/videos of people without clothes when you didn't want to see?

Has anyone taken pictures of you without clothes on?

Emotional Abuse Screening

Adults yell/call names regularly?

Threatened to hurt you/family/pets?

Adults love and want you safe?

Neglect Screening

Enough food at home?

Safe place to sleep?

Adults help when sick?

Left alone for long periods?

Domestic Violence Exposure

Seen adults at home hurt each other?

Adults yell/scream in scary ways?

Digital / Online Abuse (Adolescents 12+)

Has anyone online asked to meet in person or for personal information?

Has anyone sent pictures/messages online that made you uncomfortable?

Has anyone threatened or tried to scare you through text/social media/online?

Disclosure & Safety

Anything making you feel unsafe?

If you told someone about being hurt or scared, do you think you would get in trouble or that something bad would happen?

Trusted adult to talk to?

Trusted adult relationship

Referral Needed (ACEs)

⚠️ Violence & Unintentional Injury

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Bullying

Q1. During this school year, how often have you been bullied at school?

Q3. During this school year, how often have you bullied others?

Vehicle Safety

Q6. Seatbelt when riding as passenger?

Q7. Seatbelt when driving?

Q8. Past 30 days, rode with driver who had been drinking?

Physical Fights

Q9. Physical fights (past 12 months)?

Q10. Physical fights on school property (past 12 months)?

Injuries

Q11. Times injured requiring doctor/nurse treatment (past 12 months)?

Q12. Most serious injury?

Q13. Where did your most serious injury happen?

Q13a. If other place, specify:

Water Safety

Q14. How well do you swim?

Education & Counseling Provided (VI)

Bullying prevention Vehicle safety Conflict resolution Injury prevention

📎 Referrals & Notes

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General Notes (Physical & Medical)

Oral Health Notes

Reproductive/Sexual Health Notes

Psychosocial & ACEs Notes

ATOD Notes

Other Notes

Follow-up Plan

Consent & Screening

Consent obtained

✅ Mark Screening as Complete

Check this when the full screening has been reviewed and signed off. Students remain on the Incomplete list until this is marked.

Screening Completed

⚙️

Manage Users

Add or remove user accounts

Add New User

Full Name *

Email *

Password *

Role

Provider Code *

Current Users

Name	Email	Role	Provider Code	Action