Department of Education

Student’S HealtH RecoRd

Student Address Label
Name Female ❑ Preschool: Entry Date / /
(Last) (First) (Middle Initial)
Male ❑ Elementary: Entry Date / /
Birthdate Intermediate/Middle: Entry Date / /
Month Day Year
High: Entry Date / /
(Mother/Legal Guardian) (Father/Legal Guardian) Allergies:
Please complete the following sections (CHECK IF YES)
MEDICAL STATUS
Allergy (type) ❑ Cancer/Leukemia ❑ Hearing Problems ❑ Hypertension ❑ Seizures ❑ Vision Problem ❑
Asthma ❑ Chronic Cough/Wheezing ❑ Heart Disease ❑ JRA Arthritis ❑ Sickle Cell Anemia ❑
Behavioral Problems ❑ Diabetes ❑ Hemophilia ❑ Rheumatic Heart ❑ Skin Problems ❑
PHySician’S examination code: n-noRmal; a-abnoRmal; c-coRRected; R-Receiving caRe

See Results Below

PPD Screening
(Check if Yes)

(Check if Yes)
Immunization
Extremities

Completed
Varicella

Reviewed
Abdomen

Record
Pressure

Scoliosis
Nervous

Nutrition
Vision Hearing Immunity

System
Weight

Date
Height

Throat
Grade

Lungs
Secondary to
Blood

Teeth
Heart
or Printed Name

Nose
Eyes
Ears

Skin
BMI

Disease (DATE)
R. L. R. L.

/ / / /

/ / / /
tubeRculoSiS evaluation immunizationS (vaccineS, dateS given: montH/day/yeaR)
Check one box below, complete date Physician, DTaP, DTP, DT, Type
assessment, test or x-ray was administered. APRN, PA,Clinic Tdap or Td
Date / / / / / / / / / / / /
Negative Date: Type
Polio
TB Risk Assessment / / (IPV or OPV)
Date: Date / / / / / / / / / / / /
Negative test for
TB infection Hib (Haemophilus Type
/ / influenzae type b )
Positive test, and Date: Date / / / / / / / / / / / /
negative chest x-ray / / Type
Pneumococcal
Conjugate Date / / / / / / / / / / / /
dental examination Type
Date: Hepatitis B
Dental Check-Up Date / / / / / / / / / / / /
/ /
Date: Type
Dental Check-Up Hepatitis A
/ /
Date / / / / / / / / / / / /
Type Varicella
MMR
Date / / / / / / / /Date / / / /
Type Meningococcal
HPV Conjugate
Date / / / / / / / /Date / / / /
Type
Other
Date / / / / / / / / / / / /

Physician, APRN, PA or Clinic

Health History Comments:
(Please Print)

Date Signature & Title Date Signature & Title

State of Hawaii Benefit, Employment & Support Services Division
Department of Human Services

Early Childhood Pre-K Health Record Supplement*

Name of Child: Name of Child Care Facility:
Child’s DOB: To Be Completed By The Physician
1. Type Screening 2. Date 3. Results 4. Recommendations/Follow up
Completed
Head Circumference (up to 2yrs old)
Normal Abnormal
Hgb/Hct
Normal Abnormal
Lead
Normal Abnormal
BMI (≥ 2 years old)
Normal Counsel
Developmental Screening
Tool: □ PEDS □ ASQ
No Concern Concern
□ Other _________________________

5. Medical Conditions 6. Special Care 7. Recommendations 8. EC Provider

Plan Needed Use Only
Allergies/Sensitivities None Special Care
List: Yes No Plan completed

Medications/Treatments None Special Care

List: Yes No Plan completed

Special Diet prescribed by physician None Special Care

List: Yes No Plan completed

Behavioral Issues/Social Emotional Concerns None Special Care

List: Yes No Plan completed

Medical Conditions/Related Surgeries None Special Care

List: Yes No Plan completed

9. Physician/NP/APRN/PA or Clinic Name, Address, Zip, Phone, Fax 11. I give my consent for my child’s Health Care Provider to discuss the information on this form
with my Early Childhood Provider
_____________________________________________________________________________
Early Childhood Provider Name
12. Parent/Guardian Name

10. Physician/NP/ APRN/ PA or Clinic Signature (Signature or stamp) Date 13. Parent/Guardian Signature Date

*Supplement to the STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 2010, RS 09-1051 (Rev. of RS 06-0698)
DHS 908 (09/15) Page 1 of 4
State of Hawaii Benefit, Employment & Support Services Division
Department of Human Services

Instructions for Completing the Early Childhood Pre-K Health Record Supplement

To Be Completed by the Physician (Please print)

1. Type of Screening: Check all that apply. 7. Recommendations

Head Circumference, Hgb/Hct, Lead, BMI Write your recommendations, e.g., “Medications must be
Developmental Screening: The screening tools listed are: administered by the parent before or after school hours.”
PEDS: Parent’s Evaluation of Developmental Status
ASQ: Ages and Stages Questionnaire 8. Early Childhood Provider Use Only
Other: Print the name of screening tool used. This section is designated for the early childhood provider to
complete if physician has marked (X) Yes in Box 6. Sample forms
2. Date Completed of the Special Care Plans can be requested from Department of
Write the date mm/dd/year the screening was performed. i.e., Human Service (DHS) office, phone or downloaded from the
06/01/2006. Department of Human Service website.

3. Results 9. Physician/NP/APRN/PA or Clinic Name

Mark (X) to indicate “Normal” or “Abnormal”, “No Concern” or Type or print legibly physician, nurse practitioner, advanced
“Concern”, “Normal” or “Counsel”. If the box is marked practiced registered nurse, physician assistant or clinic name,
abnormal, concern or counsel, please complete Box 4. address, zip, phone, and fax.
Recommendations/Follow up.
10. Physician/NP/ APRN/ PA, of Clinic (Signature or Stamp) and
4. Recommendations/Follow up Date:
Please complete if abnormal, concern or counsel is selected. Physician, nurse practitioner, physician assistant must sign his/her
name or stamp and write in the date of child’s examination.
5. Medical Conditions
Mark (X) “None” box for each item if the child has no 11. “I give my consent for my child’s Health Care Provider to
Allergies/Sensitivities, Medications/Treatments, Special discuss the information on this form with my Early Childhood
Diet prescribed by physician, Behavioral Issues/Social provider.”
Emotional Concerns, Medical Conditions/ Related The Early Childhood program is encouraged to type, print legibly,
Surgeries. List type of medical condition, e.g., Medical or stamp the program name here prior to parent signature.
Condition/Related Surgeries List: Asthma
12. Parent/Guardian Name
6. Special Care Plan Needed Print the name of the Parent or Guardian
If child has a medical condition and the Early Childhood Provider
should develop a special care plan, mark (X) Yes, next to the 13. Parent/Guardian Signature
appropriate category. If child does not need a special care plan, The Parent or Guardian must sign his/her name and write the
mark (X) No. date signed.

DHS 908 (09/15) Page 2 of 4