Health Appraisal Form - Manhasset Public Schools
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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). This form is for Manhasset Public School use only.
MANHASSET PUBLIC SCHOOLS HEALTH APPRAISAL FORM
Name: ______________________________________________ Date of Birth: ________________
Address:____________________________________________ Grade(as of Sept.) ____________
School: __________________ Gender: M F
IMMUNIZATIONS / HEALTH HISTORY
: ____
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: _______________________________________________
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: _________________
PHYSICAL EXAM
.
Height: _______
Weight: _______
Blood Pressure: _________
Date of Exam: ____________
_____________
Referral
Body Mass Index: ___ ___ . ___
Vision – w/o
R
L
Weight Status Category (BMI Percentile
glasses/contacts
th
th
th
less than 5
5
through 49
Vision – with
th
th
th
th
50
through 84
85
through 94
glasses/contacts
th
th
th
95
through 98
99
and higher
Vision – Near Point
Hearing Pass 20 db sc
both ears
EXAM ENTIRELY NORMAL
Tanner: l. 11. 111. 1V. V. Scoliosis: Negative Positive
Specify any abnormality ______________________________________________________________
Specify any abnormality (use reverse of form if needed): ________________________________________
MEDICATIONS
Medications (list all):
None
Name: ________________________________________Dosage/Time: ____________________________
Name: ________________________________________Dosage/Time: ____________________________
Please consult School Nurse regarding medication for emergency sheltering.
PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK QUALIFICATION/CSE
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
Specify medical accommodations needed for school: _________________ None
Known or suspected disability: ___________________________________ Please monitor
Restrictions: ___________________________________________________ Please monitor
Protective equipment required: Athletic Cup Sport goggles/impact resistant eyewear Other: __
Provider’s Signature: __________________________Phone: _________ Stamp:
Provider’s Name/Address ______________________ Fax: ___________
Parent Signature: ________________________ Date: _______________
This exam complies with NYSED requirements above and is valid for twelve months. For interscholastic sports participation in the
st
secondary schools this physical must be performed AFTER MAY 31
.
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