EVALUATION GUIDE
Directions: Include pertinent criteria from the list below in your report. Be sure to cite your sources of information. Information shared should be educationally relevant. Your report should be sent to the AEA primary contact or teacher prior to the staffing date and it will be mailed to the parent as part of the Special Education Staffing Report. Remember to spell out all medical abbreviations and to type your report in complete sentences.
Health History Outline (Italics note required special education evaluation report components)
I. Health Examinations and Screening
A. Results of most recent hearing/ vision screening
B. Results of last physical, name and title of examiner
Rate of development over time
II. Past Medical History
A. Pregnancy information/ Adoption /Prenatal information
1. General health before and during pregnancy
2. Substance abuse before and during pregnancy (tobacco, alcohol, drugs)
3. Chemical exposures
4. Any complications that required medical attention
B. Delivery Information
1. Length of pregnancy
2. Length of labor (complications)
3. Baby’s condition at birth
4. Congenital anomalies
5. Any oxygen, medication, procedures, or other interventions required in the first weeks of life
C. Developmental Milestones
1. Any concerns?
2. Any identified delays? If yes, what services or remedial actions were taken?
D. Past Medical History
1. Serious illnesses / hospitalizations/ surgeries (no need to give dates)
2. Chronic conditions (include allergies)
3. Accidents requiring medical treatment
4. Immunizations current
5. History of abuse or neglect (if educationally relevant)
Current Status
III. Present Health Status
A. Nutrition
1. Ht., Wt., growth chart information (for those who are over or under weight)
2. Dietary restrictions/ concerns (chewing, swallowing, etc.)
B. Any routine medications, treatments, equipment, or procedures
C. Systems assessment
D. Emotional or behavioral concerns
E. Activity level
F. Physical limitations
Student Needs at School
IV. Related Services/ Modifications/Adaptations/Accommodations Required
- Is an individual health plan and/or emergency plan required? If yes, where is it located?
- What modifications, or adaptations, or accommodations may be required for health reasons during the school day?
- Any medications, treatments, or procedures required during the school day?
- Any staff training required?
- Any community agencies or services provided that might impact the school?
*To entitle a student to special health services you need to provide information in your report to answer whether or not the student is eligible for special education services and what resources are required to meet the identified needs (i.e. staff time and training, handicapped accessible bathroom, assistance on the bus…).