January 2016
Hearing screening information:
Passed hearing screening: Yes No
Concerns related to student’s hearing:
Recommendations, concerns, or needs related to student’s health and required school follow-up:
School follow-up needed: Yes No
Medical Provider Comments:
Please attach other applicable school health forms:
Immunization record attached:
School medication authorization form attached:
Diabetes care plan attached:
Asthma action plan attached:
Health care plans for other conditions attached:
Health Care Professional’s Certification
I certify that I performed, on the student named above, a health assessment in accordance with G.S. 130A-440(b) that included a medical history and
physical examination with screening for vision and hearing, and if appropriate, testing for anemia and tuberculosis. I certify that the information on this
form is accurate and complete to the best of my knowledge.
Name: Title:
Signature: _________________________________________________________ Date (m/d/yyyy):
Provider Stamp Here:
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