Health Appraisal Form
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1NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports,
working permits and triennially for the Committee on Special Education (CSE).
Name:
Date of Birth:
School:
Gender:
M
F
Grade:
Immunization record attached
Sickle Cell Screen:
Positive
Negative
Not done Date:
No immunizations given today
PPD:
Positive
Negative
Not done Date:
Immunizations given since last Health Appraisal:
Elevated Lead:
Yes
No
Not done Date:
Dental Referral
Yes
No
Not done Date:
Significant Medical/Surgical History:
See attached
Specify current diseases:
Asthma
Diabetes:
Type 1
Type 2
Hyperlipidemia
Hypertension
Other:
Allergies:
LIFE THREATENING
Food:
Insect:
Other:
Seasonal
Medication:
Height: _______________
Weight: _______________
Blood Pressure: _______________
Date of Exam:
Referral
____ ____ . ____
Vision - without glasses/contact lenses
Body Mass Index:
R
L
Weight Status Category (BMI Percentile):
Vision - with glasses/contact lenses
R
L
th
th
th
th
th
less than 5
5
through 49
50
through 84
Vision - Near Point
R
L
th
th
th
th
th
85
through 94
95
through 98
99
and higher
Hearing
Pass 20 db sc both ears or:
R
L
EXAM ENTIRELY NORMAL
Tanner:
I.
II.
III.
IV.
V.
Scoliosis:
Negative
Positive:
Specify any abnormality (use reverse of form if needed):
Medications (list all):
None
Additional medications listed on reverse of form
Name: ____________________________________________________ Dosage/Time: _________________________________________________
Name: ____________________________________________________ Dosage/Time: _________________________________________________
If AM dose is missed at home: ________________________________________________________________________________________________
I assess this student to be self-directed
Yes
No
Student may self carry and self administer medication
Yes
No
Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency
sheltering is necessary at school or if the morning medication has not been given.
Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:
___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.
___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.
None
Specify medical accommodations needed for school:
Known or suspected disability:
Please monitor
Restrictions:
Please monitor
Protective equipment required:
Athletic Cup
Sport goggles/impact resistant eyewear
Other:
(Stamp below)
Provider’s Signature:
Phone:
Provider’s Name/Address:
Fax:
Parent Signature:
Date:
This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five
days that will require review by private healthcare provider and the school medical director.
Rev. 10/3/07
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