Physicians Report Of Physical Examination (Page 2 of 2) in pdf

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SYRACUSE CITY SCHOOL DISTRICT

Health Services

Sharon L. Contreras

725 Harrison Street• Syracuse, NY 13210

Superintendent of Schools

Phone 315•435•4145• Fax 315•435•4859

Dear Parents of ______________________________________________:

It is required by the New York State Health Department that each student have a physical examination

upon initial entrance, new to the school district, and routinely at grades K, 2, 4, 7, and 10. A medical

examination is also required for organized interscholastic athletic activities and/or a working paper permit. It is

suggested that these be done by the family physician, the one who best knows the child. The family physician is

better able to judge any change or deviation in the child's state of health. Findings can be discussed and referrals

(i.e., eye glasses) can then be made all in one visit. The School Physician/Nurse Practitioner examination includes:

Review of Health History

Head, Eyes, ears, nose, throat, neck and lymph nodes

Examination of heart and lungs

Palpation of the abdomen

Strength and range of motion of arms and legs

Neurological examination, reflex, balance coordination

Scoliosis (curvature of the spine)

Any bony abnormality or injury

Male examination of penis, scrotum, testes and developmental stage,

Presence/absence of hernia

Self-rating of Breast development and pubic hair and menstruation in females

These recommendations are based on New York State Health Department requirements.

Your child is scheduled to be examined ________________________________________.

Please check one of the boxes below and return this form to the school health office by ___________________.

(Date)

I give permission for my child to receive his/her physical exam in school

I will provide a physical exam by my own provider scheduled on ___________________.

(Date)

For further information, please contact your school nurse or the Health Services Office at 435-4145.

In all cases where this form is not returned, the school provider will proceed with the physical

examination per New York State law. Your child may refuse the examination. In that case you will

be required to obtain the examination by your own provider. They will not be rescheduled.

____________________________________________

Student’s Name

Signature of Parent/Guardian

____________________________________________

School

Date

Physicians Report Of Physical Examination Page 2