Solvay Union Free School District Health Appraisal Form
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1Solvay Union Free School District – Health Appraisal Form
The New York State Education Department requires an annual physical for new entrants, students in grades K, 2, 4, 7 and 10,
Interscholastic sports (yearly), working permits and triennially for the Committee on Special Education (CSE)
Student Name:
Date of Birth:
School:
Gender:
M
F
Grade:
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:
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:
PHYSICAL EXAM
Height: _______________
Weight: _______________ Blood Pressure: ______/_______ U/A: Albumin __________ Glucose ___________
Resting HR: ______Extrasystole? ______Murmur? ______After exercise/positional change: ______ Extrasystole?____ Murmur?_________
Referral
____ ____ . ____
Vision - without glasses/contact lenses
R
L
Body Mass Index:
Vision - with glasses/contact lenses
R
L
Weight Status Category (BMI Percentile):
Vision - Near Point
R
L
th
th
th
th
th
less than 5
5
through 49
50
through 84
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):
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
Free from contagions & physically qualified for all physical education, interscholastic 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:
(Stamp below)
MEDICATIONS
Medications (list all):
None
Additional medications listed on reverse of form
Name: _________________________________ Dosage ___________ Route ___________ Time: _________________ Give at school? _________
Name: _________________________________ Dosage ___________ Route __________ Time: __________________ Give at school? _________
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.)
Provider’s Signature:
Date of Exam:
______________________
Provider’s Name/Address:
Phone: ________________________ Fax: _________________
Parent Signature:
Date:
Rev. 7/15/08
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