Health Appraisal Form (Page 2 of 3) in pdf

Commack Public Schools Health Appraisal Form- TO BE COMPLETED BY PARENT/GUARDIAN

Name: _________________________________________________________

Date of Birth: ___________________________________

Address:_______________________________________________________

Home Phone # __________________________________

_______________________________________________________

Family Physician/Phone: _________________________

_______________________________________________________

Family Dentist/Phone: ____________________________

Mother’s Name_____________________________ Work # ____________________________ Cell # _______________________________

Father’s Name______________________________Work # ____________________________ Cell # _______________________________



School:

Gender:

Grade:

Teacher:

Chicken Pox ________________

Pneumonia ________________________

Diabetes ______________________

Diphtheria ___________________

Poliomyelitis ________________________

Epilepsy ______________________

German Measles ________________

Scarlet Fever _______________________

Tuberculosis __________________

Measles _______________________

Whooping Cough ___________________

TB Contact _____________________

Mumps ________________________

Rheumatic Fever ____________________

Please check each item with YES or NO

YES-PLEASE EXPLAIN AND INCLUDE DATES

1. Eye Disorder, Loss of Vision, Detached Retina

2. Ear Disorder, Hearing Loss

3. Nose Disorders

4.Throat Disorders, Thyroid Conditions

5. Facial Injuries

6. Heart Murmur, Heart Disease, Rheumatic Fever

7. Lungs, Pneumonia, Bronchitis, Asthma

8. Kidney/Bladder Disorder, Loss of Kidney

9. Abdominal, Intestinal Disorders

10. Hernia, Varicocele, Hydrocele

11. Undescended Testicle, Loss of Testicle

12. Bones/Joints- Fractures, Dislocations, Disorders

13. Head Injuries, Seizure Disorder, Loss of Consciousness

14. Allergies

15. Prescribed Medications- Regular Basis Dosage

16. Surgeries, Hospital Admissions

17. Diabetes, Endocrine Disorders

My child ______________________________has my permission to engage in all physical education programs and/or athletic activities while wearing

his/her contact lenses and/or orthodontic appliances. I understand that there is a possibility of loss of or damage to the lenses or appliances during

participation by my child in such activities. I recognize that the lenses/and or appliances can be lost, crushed or damaged during body contact activities

and other vigorous exercise. I am willing to take calculated risks involved and assume responsibility for replacement of the above, should they be lost,

( )

Contact Lenses

Orthodontic Appliances

stolen or broken.

Date

Parent/Guardian Signature

_________________________

____________________________________________________________

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. 12/4/2015