NURSE Survey - (copy)

Concern for the following student has been brought to the attention of the Student Assistance Team. Please note your observations on this form. This information will be used to help the student and his or her family to clarify the concern and determine an appropriate action.
**Multiple choice questions allow for multiple answer selections**



A red asterisk (*) indicates required questions.


  1. YOUR NAME*


  1. NUMBER OF VISITS to health office this year. *


  1. This student visits the health office greater than average as compared to the adolescent population.*
    Yes
    No


  1. NUMBER OF TIMES SENT HOME this year.


  1. Documented HEALTH ISSUE(S) or MEDICAL PROBLEM


  1. CURRENT or PAST MEDICATIONS; please note if meds are administered at school.


  1. CONTACT WITH PARENT OR GUARDIAN, please explain:


  1. PHYSICAL OBSERVATIONS*
    Student frequently visits health office for trivial complaints (explain below)
    Physical complaints, on one or more occasion, do not correlate with results of physiological examination (explain below)
    Nausea/stomachaches
    Glassy/bloodshot eyes
    Inapproppriate dress
    Poor motor skills
    Frequent cold-like symptoms
    Smell of alcohol/marijuana
    Strong smell of cologne or fragrance
    Loss of hair
    Self-injury or harm
    Poor hygiene
    Noticeable change in weight
    Fatigue
    Disoriented
    Headaches
    Food issues (explain in details section)
    Unsteady gait
    Shakey
    Dilated or constricted pupils unresponsive to light
    Eyelid tremors
    Speech irregularity- mumbled, slurred, or raspy
    Unexplained physical injuries (please explain below)
    Tatoo or piercing has needed medical attention during school hours
    NONE of the ABOVE


  1. Details about physical observations:


  1. CRISIS INDICATORS*
    Suicidal threats/gestures; crisis intervention for suicide
    Recent death of a family member or close friend
    Has expressed desire to join someone who has died or glamorizes death
    Family member or friend has severe or life threatening medical issue
    Exhibits self-harming behaviors
    Indication of living in an at-risk environment (explain in details section)
    Other stressors (explain in details section)
    NONE of the ABOVE


  1. Details from Crisis Indicators section:


  1. ATYPICAL BEHAVIOR; check all that apply*
    Crying or tearful
    Inappropriate sexual verbalization or actions
    Expresses involvement in the occult or hate groups through verbalization or dress
    Expresses anger towards parent or other authority figure
    Expresses hopelessness, worthlessness, helplessness
    Appears fearful
    Appears anxious
    Lies (explain below)
    Criticizes self or others
    Seeks constant reassurance
    Dramatic/sudden change in behavior (explain in details section)
    Frequently absent with no prevailing medical issue
    Student appears to utilize health office to avoid class time
    NONE of the ABOVE


  1. Details from the Atypical Behavior section:


  1. IF student has been medically assessed upon request of security or administration, please note any observable behavior or mood during that assessment, otherwise please leave this question blank:
    Angry
    Hostile
    Sad
    Silly
    Remorseful
    Fidgety
    Anxious
    Tremors
    Combative
    Confused
    Crying
    Lethargic
    Demanding
    Disrespectful
    Impatient
    Compliant with building procedures
    NONE OF THE ABOVE


  1. Student has shared the following information with the health office staff:
    Employed 20+ hours per week
    Student provides substantial care for the household or siblings
    Committed to many extra curricular activities
    Financial problems or financial needs not met
    Student not living at home
    Absence of caregiver in the home
    Non-compliant with physician's orders
    Does not take medications as prescribed by physician
    Sleeps less than recommended number of hours for adolescent or difficulty sleeping
    The student's significant other is controlling or abusive
    Social problems
    School anxiety
    Expresses concern with personal health issues
    Expresses negative perception of body image
    Student is being bullied or harassed (explain below)
    Openly expresses alcohol / other drug use
    Shares his/her friends use alcohol or drugs
    NONE OF THE ABOVE


  1. In the space below, please note any other pertinent information or observations about this student:


  1. Nurse has consulted with the following professionals about this student:
    administration
    security
    school counselor
    child study team
    SAP
    treating physician (PTC on file)
    mental health provider (PTC on file)
    other
    NONE OF THE ABOVE





CB South
Warrington, PA