STUDENT ASSISTANCE TEAM CHECKLIST (Nurse ONLY)

 

Your Name:    Name of Student:  Date: 

 

MEDICAL HISORY

Significant Medical Problems:

 

Height:   

Weight:  

Hearing: 

Vision:   

Medications: 
Significant contact with parents:

Visits to Nurses Office            

 

Number of Times Sent Home: 

PHYSICAL SYMPTOMS ATYPICAL BEHAVIOR

Unsteady on feet

Complains of nausea

Glassy, bloodshot eyes

Unexplained injuries

Skin problems

Poor motor skills

Frequent cold-like symptoms

Possible odor of marijuana

Possible odor of alcohol

Vomiting

Slurred speech

Noticeable change in weight

Hair loss

Self abusive

Poor hygiene

Preoccupied with health issues

Fatigue

Disoriented

Cries

Expresses openly drug use

Expresses desire to punish or gain revenge via violence

Inappropriate sexual verbalization

Sudden change in behavior

Lying

Express hopelessness, worthlessness, helplessness

Express fear/anxiety

 

Further Concerns: