ࡱ> ikh? $&jbjb "`}}=l       <<<<8t|L</&`v ( VP,......,U uZ B BBZ   `B   , .    B,,  ,<$ <<^@,,//,, FORMCHECKBOX  Initial  FORMCHECKBOX Annual  FORMCHECKBOX 3Yr.  FORMCHECKBOX Other:  FORMTEXT        FORMCHECKBOX Annual  FORMCHECKBOX 3Yr. Student Name:  FORMTEXT      ,  FORMTEXT        FORMTEXT  . Birthdate:  FORMTEXT       Age:  FORMTEXT        FORMCHECKBOX male  FORMCHECKBOX female School:  FORMTEXT       Grade:  FORMDROPDOWN  Room:  FORMTEXT       Track:  FORMDROPDOWN  Spec. Ed. Eligibility (if applicable)  FORMTEXT       Current Informant(s):  FORMTEXT       Relationship:  FORMTEXT       Date:  FORMTEXT       Home Language:  FORMTEXT       Translator s name if applicable:  FORMTEXT       A) DEVELOPMENTAL HISTORY (For Initial Assessment Only) 1) Prenatal history:  FORMCHECKBOX Full Term  FORMCHECKBOX Premature  FORMTEXT    weeks Birth weight  FORMTEXT       lbs.  FORMTEXT    oz. Delivery:  FORMCHECKBOX Vaginal  FORMCHECKBOX C-section 2) Birth Place:  FORMTEXT       Born at:  FORMCHECKBOX  Hospital  FORMCHECKBOX  Other:  FORMTEXT       Home with Mother:  FORMCHECKBOX Yes  FORMCHECKBOX No 3) List Prenatal/Birth/ Newborn Complications:  FORMTEXT       4) Milestones: Sat Alone  FORMTEXT       Months Crawled  FORMTEXT       Months Walked  FORMTEXT       Months First Word(s)  FORMTEXT       Months Sentences  FORMTEXT       Months Toilet Trained (days)  FORMTEXT       (age) Toilet Trained (nights)  FORMTEXT       (age) 5) Comments:  FORMTEXT       B) HEALTH HISTORY 1) Health history obtained by:  FORMCHECKBOX Interview with Parent/Guardian  FORMCHECKBOX Medical Report  FORMCHECKBOX Review of school health record  FORMCHECKBOX Other:  FORMTEXT       2) Name of Health Care Provider (if applicable):  FORMTEXT       3) Current diagnosis (if applicable):  FORMTEXT       4) Current medication(s) include time and dosage:  FORMTEXT       5) Current protocol(s):  FORMTEXT       6) Significant family health history (if applicable):  FORMCHECKBOX No  FORMCHECKBOX Yes, summarize:  FORMTEXT       7) Parent areas of concern:  FORMCHECKBOX Academic  FORMCHECKBOX Behavior at Home/School  FORMCHECKBOX Physical Health  FORMCHECKBOX Development  FORMCHECKBOX Social/Peer Relationships  FORMTEXT       8) Summarize/update health history (include serious/ chronic illness, allergies, injury, accident, surgery, hospitalization, counseling, or psychiatric care):  FORMTEXT       9) Additional information including outside services, previous screenings and developmental update (if applicable):  FORMTEXT       C) HEALTH ASSESSMENT 1) Date:  FORMTEXT       Height:  FORMTEXT       inches,  FORMTEXT       % Weight:  FORMTEXT       lbs.,  FORMTEXT       % Blood Pressure:  FORMTEXT    / FORMTEXT     2) Date:  FORMTEXT       Vision: Without Correction: R 20/ FORMTEXT       L 20/ FORMTEXT       Both 20/ FORMTEXT       Referred:  FORMTEXT       With Correction: R 20/ FORMTEXT       L 20/ FORMTEXT       Both 20/ FORMTEXT       Referred:  FORMTEXT       3) Date:  FORMTEXT       Audio:  FORMCHECKBOX Yes  FORMCHECKBOX No Passed/Failed:  FORMTEXT       Referred:  FORMTEXT       4) Activities of daily living (ADL):  FORMCHECKBOX Independent  FORMCHECKBOX Needs assistance (Include toileting, feeding, use of hands and arms) Summarize:  FORMTEXT       5) Mobility:  FORMCHECKBOX No assistance needed  FORMCHECKBOX  Leg braces  FORMCHECKBOX  Walker/crutches  FORMCHECKBOX Wheel chair with assistance  FORMCHECKBOX Wheel chair without assistance 6) Additional referral(s):  FORMTEXT       7) Comments:  FORMTEXT       Completed by:  FORMTEXT       Signature: Date:  FORMTEXT       Form 33.19 LOS ANGELES UNIFIED SCHOOL DISTRICT Nursing Services SCHOOL NURSE HEALTH ASSESSMENT Original: Place in the Student s Health Card envelope  PAGE 1 of  NUMPAGES 1 (E-Form by T. Yamane, ITAF, District A 3/27/03)  "68TVXhj  <>@JNjzle CJOJQJjCJOJQJUjNCJOJQJUjCJOJQJU CJOJQJjCJOJQJUmHjCJOJQJUjbCJOJQJUjCJOJQJUjvCJOJQJUjCJOJQJU CJOJQJjCJOJQJU'JLN v x #$$d%d'dNOQa$ @@  X @  r  !D%  X D%N"&#$+D/  X D% TV <>JLNBLnp  @ J z | > H  h r v x 0 2 f h   T V NP|zdjl (*>@BLNPRnpr|~~w CJ OJQJjCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUj"CJOJQJUjCJOJQJUjCJOJQJUmHj:CJOJQJU CJOJQJjCJOJQJU.   & ( < > @ J L \ ^ z | ~ $ & : < > H J h j ~ xj CJOJQJUj CJOJQJU CJ OJQJj CJOJQJUjTCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUmHjtCJOJQJUjCJOJQJU CJOJQJ/  N P d f h r t v x   0 2 4 H J f h j ~ ̨zlj CJOJQJUjF CJOJQJUj CJOJQJUjCJOJQJU CJOJQJ5CJOJQJj^ CJOJQJUj CJOJQJU CJ OJQJjCJOJQJUmHjt CJOJQJUjCJOJQJU CJOJQJ) xH0 !  6$@@$d%d&d'dNOPQ+ !@@$d%d&d'dNOPQ- ~ !@$d%d&d'dNOPQ- @ d!@$d%d&d'dNOPQ      6 8 T V X h j 02NPRbvjCJOJQJUj~CJOJQJUjCJOJQJU>*CJOJQJjCJOJQJUj CJOJQJUj CJOJQJUj0 CJOJQJU CJOJQJjCJOJQJUjCJOJQJUmH.bdxz|`bvxz&(FH\^`jl~j(CJOJQJUjCJOJQJUj<CJOJQJUjCJOJQJUjPCJOJQJUjCJOJQJUjCJOJQJUmHjfCJOJQJU CJOJQJjCJOJQJU/$&JTTR* @@@$d%d&d'dNOPQ) 8$d%d&d'dNOPQ- 8 t"@@$d%d&d'dNOPQ) @@$d%d&d'dNOPQ &`j`j $&JL HJ`jnpdnrtXZ$&XZ&(^x,.Zdxz|aFH\^`jl "$&JҶҨҚҒ}jCJOJQJU CJOJQJ>*CJOJQJjjCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJU CJOJQJjCJOJQJUmHjCJOJQJUjCJOJQJU+JLnprtY' @$d%d&d'dNOPQ' @$d%d&d'dNOPQ* 4 !$d%d&d'dNOPQ* HBt"@$d%d&d'dNOPQ   *,HJLFH\^`jlJL`bdnpߵߚߌ~pjCJOJQJUjCJOJQJUjCJOJQJUj.CJOJQJUjCJOJQJUmHjCJOJQJUjBCJOJQJUjCJOJQJU CJOJQJjCJOJQJUjVCJOJQJU,:<XZ\bd$&(:<XZ\ &(~pj@CJOJQJUjCJOJQJUjTCJOJQJUjCJOJQJUjhCJOJQJUjCJOJQJUj|CJOJQJUjCJOJQJU CJOJQJjCJOJQJUmHjCJOJQJU,^-  dX $d%d&d'dNOPQ' ,@$d%d&d'dNOPQ' @$d%d&d'dNOPQ (*^`tvx,@BVXZdfxzj CJOJQJUjCJOJQJUjCJOJQJU5CJOJQJjCJOJQJUj,CJOJQJUjCJOJQJUmHjCJOJQJU CJOJQJjCJOJQJU0,.[) T $d%d&d'dNOPQ, T H$d%d&d'dNOPQ* T H$d%d&d'dNOPQ$$$d%d'dNOQa$ !@:DnprNXLV~0:ln   " $ T!!!!!!!"""T"V"""""4#6#######d "68:DFnp46JLNXZfh|~ҶҨҚҌ~jN#CJOJQJUj"CJOJQJUjb"CJOJQJUj!CJOJQJUjr!CJOJQJUj CJOJQJU CJOJQJjCJOJQJUmHjCJOJQJUj CJOJQJU124HJLVXdfz|~,.0ҶҨҚҌ҄vjL&CJOJQJU>*CJOJQJj%CJOJQJUjl%CJOJQJUj%CJOJQJUj$CJOJQJUj"$CJOJQJU CJOJQJjCJOJQJUmHjCJOJQJUj#CJOJQJU." yG2 T  x$d%d&d'dNOPQ) T $d%d&d'dNOPQ- xB<$d%d&d'dNOPQ/ TxB<$d%d&d'dNOPQ0:<NPlnpxz    n p j!l!!!!!!!!!~j)CJOJQJUj)CJOJQJUj(CJOJQJUj$(CJOJQJUj'CJOJQJUj8'CJOJQJUj&CJOJQJU CJOJQJjCJOJQJUjCJOJQJUmH." $ T!!!4#6#######~xx !- @ ,&J$d%d&d'dNOPQ' @$d%d&d'dNOPQ* T @$d%d&d'dNOPQ !!!!!"""6"8"T"V"X"z"|"""""""""l#n###############$$$$ $:$ߵߧߙ~pj6-CJOJQJUj,CJOJQJUjCJOJQJUmHjJ,CJOJQJUj+CJOJQJUj^+CJOJQJUj*CJOJQJUjr*CJOJQJU CJOJQJjCJOJQJUj)CJOJQJU,#####$$$l$v$x$z$$$$:%<%%%%%%& &!&"&#&$&:$D$R$T$h$j$l$v$x$z$$$$$8%:%<%%%%%%%%%%%%%%% &!&#&$&żv0JCJ OJQJ0JCJOJQJmHj0JCJOJQJU0JCJOJQJ 5OJQJ5CJOJQJ CJOJQJ CJOJQJ0JCJOJQJOJQJjCJOJQJUmHj-CJOJQJUjCJOJQJU CJOJQJ>*CJOJQJ"#z$$$$:%<%!&"&#&$&  !|)$a$$a$   ! / =!"#$%vDeCheck31vDeCheck32vDeCheck33vDeCheck34vDText69vDeCheck32vDeCheck33tDText1tDText2tDText3DText4M/d/yyvDText47tDeCheck1tDeCheck2tD#Text5Df Dropdown1Pre-Kind Kindergarten123456789101112N/AOthervDText70Df Dropdown2LEARNABCD TraditionalOthervDText48tDText9vDText49vD Text50tDText6tDText8tDeCheck3tDeCheck4vDText73xDText510xDText520tDeCheck5tDeCheck6vDText53tDeCheck7tDeCheck8vDText54tDeCheck9vDeCheck10vDText55vDText13vDText14vDText15vDText16vDText17vDText18jDvDText72vDeCheck11vDeCheck12vDeCheck13vDeCheck14vDText56vDText57vDText58vDText20vDText59vDeCheck15vDeCheck16vDText60vDeCheck17vDeCheck18vDeCheck19vDeCheck20vDeCheck21vDText71vDText61vDText62D Text63M/d/yyvDText26vDText27vDText28vDText29xDText300xDText310DText32M/d/yyjDjDjDvDText65jDjDjDvDText65vD M/d/yyvDeCheck22vDeCheck23vDText34vDText64vDeCheck24vDeCheck25vDText66vDeCheck26vDeCheck27vDeCheck28vDeCheck29vDeCheck30vDText67vDText68vDText44D Text43M/d/yy i@@@ Normal CJOJPJQJ_HmH sH tH 66 Heading 1$$@&a$>*00 Heading 2$@&>*t@t Heading 3L$$ @@$d%d'd@&NOQa$5<A@< Default Paragraph Font,@, Header  !, @, Footer  !&)@& Page Number$` z$aaj b(0!:$$&!"$'(*,. J" #$& #%)+/#$&&-+4DK[couw  &(8>N`lr{$4@FNZ`r~ $4?KNcou| (1=CWgl| #/5LX^q} EUu#/5^jp-1AR^d  / ; A l x ~     " 7 C G I U Y e q w  % + 2 > D O [ a m y   7 G T d +=Mjz )5;$G$G$G$G$FG$G$FFFFFG$G$FS$FS$FFFFFFG$G$FFFG$G$FG$G$FG$G$FFFFFFFFFG$G$G$G$FFFFFG$G$FG$G$G$G$G$FFFFFFFFFFFFFFFFFFFFG$G$FFG$G$FG$G$G$G$G$FFFF!SCheck31Text1Text2Text3Text4Text47Check1Check2Text5 Dropdown1Text70 Dropdown2Text48Text9Text49Text50Text6Text8Check3Check4Text73Text51Text52Check5Check6Text53Check7Check8Text54Check9Check10Text55Text13Text14Text15Text16Text17Text18Text72Check11Check12Check13Check14Text56Text57Text58Text20Text59Check15Check16Text60Check17Check18Check19Check20Check21Text71Text61Text62Text63Text26Text27Text28Text29Text30Text31Text32Text65Check22Check23Text34Text64Check24Check25Text66Check26Check27Check28Check29Check30Text67Text68Text44)?a|5Os %@d}2Xm$MrFv$_2S 0 m  8 J f 8 U >k%  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQR'9Os%Ga5Ov)Dh}6_V6q.Be B  # H Z x   H e ,N{%=%,4 {=%:::: T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a2.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a2.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a2.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a2.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a2.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a3.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a4.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a4.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a4.dot T. Yamane/Macintosh HD:Desktop Folder:HealthAssess1a5.dot@D G 2D D  $PPP P PPPPPPPPPP P"P$PL@GTimes New Roman5Symbol3 Arial;Helvetica3Times qhuu5 C S'>0dt,3qH#LOS ANGELES UNIFIED SCHOOL DISTRICT Ted Yamane T. Yamanetoad Oh+'0 $ @ L Xdlt|'$LOS ANGELES UNIFIED SCHOOL DISTRICTOS  Ted Yamane ed HealthAssess1a4.dot T. Yamaness2 YMicrosoft Word 9.0@@P:P!@P:P!5  ՜.+,0  hp|  ' Nt $LOS ANGELES UNIFIED SCHOOL DISTRICT Title  !"#$%&'()*+,-./023456789:;<=>?@ABCDEFGHJKLMNOPQRSTUVWYZ[\]^_abcdefgjRoot Entry Fx!lData 1..1TableIWordDocument"`SummaryInformation(XDocumentSummaryInformation8`CompObjXObjectPoolx!x! FMicrosoft Word DocumentNB6WWord.Document.8