HEALTH ASSESSMENT PROFORMA OF SCHOOL

STUDENTS
NAME: ____________________________________________________________________
AGE: ________________________SEX: _________________CLASS: __________________
VITAL SIGNS:
Temp: ______ Pulse: -_________beats/min Resp: _________breaths/min BP:
________
PHYSICAL:
Height: _________cms Weight: __________kg BMI: ____________
Walking gait: Normal ☐ Abnormal ☐
ORIENTATION:
☐ Person ☐ Place ☐ Time ☐ Situation
MENTAL STATE:
☐ Calm ☐ Cooperative ☐ Uncooperative ☐ Restless
SKIN:
 Temperature: ☐ Normal ☐ Raised
 Moisture: ☐ Clammy ☐ Diaphoretic ☐ Dry
 Turgor: ☐ Elastic ☐ Tented ☐ Edema
 Colour: _________
 Wound/Scabies: __________
 Skin rash/Pimples: ☐ Present ☐ Absent
HAIR:
Texture: ____________ Colour: ____________ Presence of lice/dandruff: Yes ☐ No ☐
EYES:
Conjunctiva: ☐ Pink ☐ Moist ☐ Conjunctivitis ☐ Pallor
Pupils: ☐ Equal ☐ Round ☐ Reactive to light
Sclera: ☐ White ☐ Bitot’s spot
Abnormal discharge: ☐ Yes ☐ No
Visual acuity: ☐ Left: ☐ Right:
Colour blindness: ☐ Present ☐ Absent
MOUTH AND TEETH:
 Moist ☐ Dry ☐
 Dental carries- Yes ☐ No ☐
 Glossitis- Yes ☐ No ☐
 Gum bleeding- Yes ☐ No ☐
 Pyorrhea - Present ☐ Absent ☐
 Any cracks in tongue - Yes ☐ No ☐
Others: _______________________________
EARS:
Symmetrical - Yes ☐ No ☐ Lesions- Present ☐ Absent ☐
Hearing devices - Present ☐ Absent ☐ Earwax/Discharge- - Present ☐ Absent ☐
NOSE:
Symmetrical- - Yes ☐ No ☐ Congestion/Nasal septum deviation- Yes ☐ No ☐
NECK AND THROAT:
Symmetrical- Yes ☐ No ☐ Range of motion: Active☐ Passive ☐
Thyroid swelling- Yes ☐ No ☐ Jugular vein distention: - Yes ☐ No ☐
Any other: _______________
CHEST:
INSPECTION: Symmetrical: Yes ☐ No ☐ Convex ☐ Round ☐
Any venous engorgement: Yes ☐ No ☐
PALPATION: Any abnormal swelling- Present ☐ Absent ☐
HEART SOUNDS: S1 ☐ S2 ☐ S3 ☐ S4 ☐ Any other sounds__________
BREATHE SOUNDS:
Vesicular breath sounds: Present ☐ Absent ☐
Any other sounds: _____________________
ABDOMEN:
Any umbilical discharge: Yes ☐ No ☐ Liver and spleen palpable: Yes ☐ No ☐
Any other abnormal swelling(hernia): Yes ☐ No☐ Renal angle tenderness Yes ☐ No ☐
IPS: Normal ☐ Abnormal ☐
UPPER EXTREMITIES:
Symmetrical: Yes ☐ No☐ Capillary refill(<3sec): Yes ☐ No☐
Range of motion: Active☐ Passive ☐
Polydactyly /Syndactyly/webbed finger: Present ☐ Absent ☐
LOWER EXTREMITIES:
Symmetrical: Yes ☐ No☐ Range of motion: Active☐ Passive ☐
Any venous engorgement: Present ☐ Absent ☐
Pedal edema: Present ☐ Absent ☐
Abnormal swelling: Present ☐ Absent ☐
BACK:
 Skin: Moist Dry
 Any swelling: Present ☐ Absent ☐ Surgical scars: Present ☐ Absent ☐
 Any deformities:
Scoliosis: Present ☐ Absent ☐ Kyphosis: Present ☐ Absent ☐
Lordosis: Present ☐ Absent ☐
Any other abnormalities : ____________________________________

REMARKS:

DATE: SIGNATURE OF EVALUATOR