Florida law (s. 1003.22, F.S.) requires a health examination within one year before a child enters a Florida public or private school, from pre-kindergarten through grade 12, and this two-page form documents it. Clinicians meet it at a school entry physical. The parent takes the original to the school, where it is kept in the child's Cumulative Health Folder for school and health personnel.
A health professional licensed in Florida, or in the state where the student lived at the time of the exam, and authorized to perform a general health exam completes and signs page 2, Part II Medical Evaluation. The parent, or an interviewer in the provider's office, completes the identifying information and Part I medical history on page 1.
Fill in the child's last, first and middle name, birth date, sex, address, school, grade, home telephone and the parent or guardian's full name. FDOH's instructions call this information critical for distinguishing between children with the same or similar names, so do not drop the middle name or abbreviate the parents' names.
The parent, or an interviewer in the provider's office, answers eight yes or no questions before the exam: general health concerns, other illness or social, emotional or behavioral problems, allergies, prescription medication, vision, hearing or speech problems, hospitalization or surgery, significant injury, and whether the parent wants to talk with a school nurse. Each yes is explained below, and the parent signs consent for school staff to use Parts I and II.
Three recommended, not required, services: a comprehensive vision exam for ages 3 to 5 by an optometrist or ophthalmologist, a comprehensive dental exam by a dentist, and a hearing screening, which the provider doing the school entry exam may perform. The provider of each service records the exam date, results and any corrective action or accommodations needed.
Repeat the child's name and birth date as on page 1, then enter the month, day and year of the complete history and physical, which must fall within one year of enrollment. Record height, weight, BMI percentile, blood pressure, hematocrit or hemoglobin, lead and urinalysis. Give visual acuity for each eye with and without glasses, and hearing for each ear as passed, failed or referred.
Mark gross dental, head, scalp and skin, eyes, ears, nose and throat, chest, lungs and heart, abdomen and postural assessment as normal or abnormal, noting any referral or treatment. Check TB risk assessment done after reviewing the guidelines at the bottom of the page. Do not write the TB screening or its results on this school form.
Check vision, hearing, speech or language, physical, social or behavioral, or cognitive problems that may affect learning and specify them, then note any health condition that may require emergency action at school, such as seizures or allergies. The form is stored in the Cumulative Health Folder and is not protected like a medical record, so FDOH asks providers to leave out confidential information such as child abuse or HIV/AIDS.
Check one: the child may participate fully in school activities including physical education, or may participate with a stated restriction or adaptation, giving the reason and the restriction. FDOH's instructions describe this as covering physical activity at recess, physical education and other physical activity during the school day. Attach an additional sheet if more space is needed.
Page 2 is to be completed and signed by the health care provider only: a licensed professional authorized to perform a general health exam certifies that it was done. Sign with your title and date, and print or stamp your name and address. The instructions ask providers to fill out or stamp the form so that it identifies the provider and their address.
Administer a Mantoux skin test if the child is a recent immigrant (under 5 years) or frequent visitor to TB endemic areas, a close contact of an active case, in frequent contact with high-risk adults, or HIV positive or has another condition that raises the risk of progression. If the child shows signs of active TB, such as cough for three weeks or longer, weight loss or loss of appetite, work up or refer for evaluation.
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School Entry Health Exam
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The exam must be completed within one year before the child enrolls in school, and the form asks the provider to enter the exam date as month, day and year for that reason. The requirement applies to entry into Florida public and private schools from pre-kindergarten through grade 12.
A health professional licensed in Florida, or in the state where the student lived at the time of the exam, who is authorized under that license to perform a general health examination. Page 2 is to be completed and signed by the health care provider only, with title, date and the provider's name and address printed or stamped.
No. The form's Tuberculosis Targeted Testing Guidelines tell providers to administer a Mantoux skin test confidentially when a child falls in a risk category, and not to record the test or related information on the form. The provider only checks that a TB risk assessment was done and arranges any follow-up with the parent.
FDOH's instructions allow two exceptions. A homeless child is given a temporary exemption for 30 school days, and a child is exempt from the exam requirement when a parent or guardian makes a written request on religious grounds. Otherwise the completed exam form documents that the s. 1003.22 requirement is met.