"Confidential Nursing Report" - New Mexico

Confidential Nursing Report is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • Released on May 1, 1999;
  • The latest edition currently provided by the New Mexico Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Department of Health.

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Download "Confidential Nursing Report" - New Mexico

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SAMPLE
Confidential Nursing Report
Special Education Students
Name: ____________________________________________ DOB: ____________________ Student ID #: ________________
School: ___________________________________________ Nurse: __________________________ Date: ________________
Check:
End of Year Report
Special Education Re-Evaluation
Child Find Screening
MEDICAL DIAGNOSIS / HEALTH PROBLEMS
1.
_________________________________________
3.
_________________________________________
2.
________________________________________
4.
________________________________________
Primary Care Physician: __________________________________ Other Physicians: __________________________________
Date of last physical exam (copy attached if Special Education Re-evaluation): ________________________________________
Immunizations Status:
Current
Non-Current (Needed:
DPT
OPV
MMR)
CURRENT MEDICATIONS
1.
_________________________________________
3.
_________________________________________
2.
________________________________________
4.
________________________________________
VISION
Distance:
Pass
Fail
Near:
Pass
Fail
Stereopsis:
Pass
Fail
Motility:
Pass
Fail
Color:
Pass
Fail
If Failed, explain: ________________________________________________________________________________________
HEARING
Screening:
Pass
Fail (If Failed, Audiogram attached) Impedance:
Pass
Fail
Otoscopic:
Pass
Fail
Comments: _____________________________________________________________________________________________
DENTAL: ___________________________________________________________________________
PHYSICAL ASSESSMENT
Ht: _____________ %ile: _____________ Wt: _____________ OFC: _____________ %ile: _____________ BP: _____________
Neurological Assessment:
Pass
Fail Comments: __________________________________________________________
General Health (attach Health History form if appropriate): ________________________________________________________
Social/Behavioral Concerns: ________________________________________________________________________________
Student Attendance: ______________________________________________________________________________________
Specialized Health Services Being Provided: ___________________________________________________________________
Summary Comments/ Recommendations: ____________________________________________________________________
(05/1999)
SAMPLE
Confidential Nursing Report
Special Education Students
Name: ____________________________________________ DOB: ____________________ Student ID #: ________________
School: ___________________________________________ Nurse: __________________________ Date: ________________
Check:
End of Year Report
Special Education Re-Evaluation
Child Find Screening
MEDICAL DIAGNOSIS / HEALTH PROBLEMS
1.
_________________________________________
3.
_________________________________________
2.
________________________________________
4.
________________________________________
Primary Care Physician: __________________________________ Other Physicians: __________________________________
Date of last physical exam (copy attached if Special Education Re-evaluation): ________________________________________
Immunizations Status:
Current
Non-Current (Needed:
DPT
OPV
MMR)
CURRENT MEDICATIONS
1.
_________________________________________
3.
_________________________________________
2.
________________________________________
4.
________________________________________
VISION
Distance:
Pass
Fail
Near:
Pass
Fail
Stereopsis:
Pass
Fail
Motility:
Pass
Fail
Color:
Pass
Fail
If Failed, explain: ________________________________________________________________________________________
HEARING
Screening:
Pass
Fail (If Failed, Audiogram attached) Impedance:
Pass
Fail
Otoscopic:
Pass
Fail
Comments: _____________________________________________________________________________________________
DENTAL: ___________________________________________________________________________
PHYSICAL ASSESSMENT
Ht: _____________ %ile: _____________ Wt: _____________ OFC: _____________ %ile: _____________ BP: _____________
Neurological Assessment:
Pass
Fail Comments: __________________________________________________________
General Health (attach Health History form if appropriate): ________________________________________________________
Social/Behavioral Concerns: ________________________________________________________________________________
Student Attendance: ______________________________________________________________________________________
Specialized Health Services Being Provided: ___________________________________________________________________
Summary Comments/ Recommendations: ____________________________________________________________________
(05/1999)