Nursing Assessment Form for Students with Special Needs
VI. STUDENTS WITH SPECIAL HEALTH CARE NEEDS
NURSING ASSESSMENT FORM for Students with Special Needs
STUDENT'S NAME:______________________ DATE of BIRTH______________
STREET ADDRESS_________________ TEL: Home_________ Work__________
CITY: _________________ CO:__________ PARENTS NAME_______________
SCHOOL NAME:__________________ EVALUATION DATE:_______________
EVALUATION SITE: (Circle One) Home School Other _______________________
DIAGNOSIS:________________________________________________________
REASON FOR EVALUATION:_________________________________________
HEALTH STATUS:___________________________________________________
EDUCATIONAL STATUS:_____________________________________________
FAMILY STATUS:____________________________________________________
PSYCHOSOCIAL CONSIDERATIONS:__________________________________
RESPIRATORY REQUIREMENTS:______________________________________
NUTRITIONAL REQUIREMENTS:______________________________________
TOILETING REQUIREMENTS:_________________________________________
MEDICATION REQUIREMENTS:_______________________________________
MOBILITY REQUIREMENTS: _________________________________________
TRANSPORTATION REQUIREMENTS:__________________________________
EMERGENCY PROCEDURES:_________________________________________
NEEDS FOR SCHOOL A TTENDANCE:_________________________________
___________________________________________________________________
The school will provide:_________________________________________________
The parents will provide:_________________________________________________
PHYSICIAN'S ORDERS:_______________________________________________
____________________________________________________________________
NURSING RECOMMENDATIONS:______________________________________
Medical services required during school:_____________________________________
___________________________________________________________________
Nursing services required during school:____________________________________
___________________________________________________________________
• Delegatable services (These must be supervised by an R.N.):____________________
___________________________________________________________________
• Non-delegatable services (These are required by the Nurse Practice Act to be done by
an R.N. or an L.P.N. -- who is supervised by an R .N.):________________________
___________________________________________________________________
Other Health Needs: ___________________________________________________
___________________________________________________________________
SUMMARY:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
School Nurse's Signature____________________________ Date:________________
Permission granted for use of this form from Anne Arundel County Health Department, School Nursing Program (Arundel County, MD).
