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Nurse Office Visit
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* Indicates required question
Date:
MM
/
DD
/
YYYY
Name
*
Last, First
Your answer
Care Administered By:
*
Your answer
Time In
*
Time
:
AM
PM
Time Out
*
Time
:
AM
PM
School
*
Mark only one circle.
Chapman High School
Chapman Middle School
Chapman Elementary
Rural Center Elementary
Blue Ridge Elementary
Enterprise Elementary
Symptoms/Assessment
*
Check all that apply.
Injury
Wound
Fever
Incontinence
Nose Bleed
Menstruation
Gastrointestinal Symptoms
Headache
Sore Throat
Cough/Sneezing
Earache
Eye Symptoms
Dental Symptoms
Skin Disorders
Breathing Issues
Stomachache
Vomiting
Lost Tooth
Rash
Bites
Other:
Required
Care Tasks
*
Check all that apply.
Blood Pressure
Splinter Removal
Eye Care
Ear Management
Dental Health
Dermatology
Concussion Baseline/Eval/Management
Ice Pack
Bandaid
Splint
Temperature
Medication
Health Ed/Counsel
Head Lice Screen
Vision Screen
Hearing Screen
Chronic Illness Management
Diabetic Care
Rest
Tooth Holder
Calamine Lotion
First Aid Cream
Phone Call
Other:
Required
Additional Assessment Info
Your answer
Parent Contact Made
*
Mark only one circle
Yes
No
Nurse Contact Made
*
Mark only one circle
Yes
No
Dismissal Avenue
*
Mark only one circle.
Return to Class
Home
Doctor
N/A
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