MEDICAL REPORT
NAME OF CHILD: ____________________________________________________STUDENT ID: __________________________
FIRST MIDDLE LAST
BIRTHDATE: ___________________ GRADE ____________ AGE ___________ DATE: _______________________
MONTH/DAY/YEAR MONTH/DAY/YEAR
PARENT(S):_________________________________________________________________________________________________
PHONE: (WORK) _______________________ (HOME) ________________________ (OTHER) __________________________
HOME ADDRESS: ___________________________________________________________ DISTRICT/AGENCY: _____________
STREET ADDRESS/P.O. BOX CITY STATE ZIP
TO BE COMPLETED BY THE SCHOOL
Referral Date____________ School Contact Person _________________________________ Phone _______________________
Medical concerns about this child are as follows:
At school
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
At home
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
NOTE: Consent for Release of Confidential Information with parent signature, is required.
TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR, DOCTOR OF OSTEOPATHY, OR
ADVANCED REGISTERED NURSE PRACTITIONER (ARNP)
Information in the following areas would be helpful to the school and parents in planning for the child’s educational needs. Please
respond as appropriate, including any applicable medical diagnoses.
General health:
Motor functioning:
Neurological findings:
Allergies:
OSDE Form 9 Page 1 of 2
Medical Report
NAME OF CHILD: ____________________________________________________STUDENT ID: __________________________
FIRST MIDDLE LAST
Dietary considerations:
Vision (attach eye report):
Hearing:
Medications, including purpose:
Other pertinent information:
Please indicate ways in which any of the above may adversely affect behavior.
Is further medical evaluation or treatment planned for any specific area?
In what ways may your medical findings affect the school’s educational or behavioral planning?
In what ways can school personnel facilitate ongoing communication with you?
If the child is involved in the Systems of Care program, please describe.
This information will be maintained in accordance with the Family Educational Rights and Privacy Act (34 CFR Part 99) and
Individuals with Disabilities Education Act (IDEA).
Medical or epidemiological information or records which identify any person as having a communicable or venereal disease (such
as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus [also known as AIDS]) shall be strictly classified as
confidential pursuant to Title 63 O.S. § 502.2.
Physician’s or ARNP’s name address, and telephone number
(typed or stamped)
_________________________________________________
Physician’s/ARNP’s Signature
_________________________________________________
Date
OSDE Form 9 Page 2 of 2
