San Elizario Independent School District

San Elizario Independent School District

Dear Parent/Guardian,
A health screening was done on your child ________________________________Grade ________ Teacher__________________
The results suggest that your child would benefit from a professional medical exam. Please take this form to your health care provider
for completion and return it to the nurse’s office.
Estimado Padre/Tutor,
Una evaluación de salud fue realizada en su hijo/a __________________Grado________ Maestra/o_________________________
Los resultados sugieren que se debe realizar un examen medico. Por favor lleve esta forma a su medico para que la complete y por
favor de regresarla a la oficina de la enfermera/o escolar.
School Nurse /Enfermera/o Escolar_________________Phone/Telfono________________ Date/Fecha_________________
Vision/Visón: Date/Fecha: _________RT Eye/Ojo derecho: 20/_______LT Eye/ Ojo izquierdo: 20/______
With glasses/ Con Anteojos ___________ Without glass/ Sin Anteojos_____________
Referred: ( ) Visual acuity ( ) Signs/ Symptoms ( ) Parent request ( ) other ___________________
Referido: ( ) Agudeza Visual ( ) Signos y sintomas ( ) Solicitud de padres ( ) Otros_____________
Please see eye specialist for evaluation/Favor de ver el especialista de los ojos
If financial assistance is needed please contact the school nurse. / Si necesita ayuda financialmente favor de
comunicarse con la enfermera/o escolar.
Comments/Comentarios ______________________________________________________________
Hearing/Oidos: Date/Fecha______
Right ear /Oido derecho 1000____2000____ 4000_________
Left ear / Oido izquierdo 1000____2000____ 4000________
*Please see your medical provider for an evaluation /Favor se ver se medico para una evaluación
Comments/Comentarios________________________________________________________________
Dental/ Dental: Postive/ Positivo
*Please see your dentist for an evaluation/Favor de ver su dentista para evaluación
Comments/Comentarios______________________________________________________________
Scoliosis/ Escolisosis: Positive/ Positivo_________________________________________________
*Please see your medical provider for an evaluation /Favor se ver se medico para una evaluación
Comments/Comentarios________________________________________________________________
Acanthosis Nigricans: Positive markings/ Marcas positivas:
WT/Peso_______ HT/Altura_________ BMI________ 1st BP/Presion________ 2nd BP/Presion
*Please see your medical provider for an evaluation/Favor de ver le medico para una evaluación
Comments/Comentarios___________________________________________________________
_______ Second notice sent/ Segunda notification Date/Fecha_______________
________Third notice sent /Tercer notification
Date /Fecha______________
If your child is already under treatment, please inform us below and return form to the nurse’s office. /
Si su higo/a se encuentra bajo tratamiento, por favor infórmenos en esta forma y regrésela a la oficina de la enfermera/o escolar.
Parent/ guardián / Padre/Tutor ______________________________________________Fecha_______________________________
Dear Health Care Provider:
Please complete the following and have the parent return this form to the school nurse.
Diagnosis___________________________________________________________________________________________________
Recommendations/Restricitons:__________________________________________________________________________________
___________________________________________________________________________________________________________
Were glasses prescribed? ____________________When are glasses to be worn? __________________________________________
Comments:__________________________________________________________________________________________________
Signature ___________________________________________________________Date_____________________________________
Revised 10/2014
Revised 10/2014