Elementary Health Appraisal Form For Grades K-5
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1Mohonasen Central Schools
Elementary Health Appraisal Form (Grades K-5)
NYSED requires an annual physical exam for all new entrants; students in Grades K, 2, 4, 7, 10, and triennially for (CSE).
Any students not presenting the required physical will be examined by the school physician during the school year.
Name:
Date of EXAM:
Gender:
M
F Date Of Birth:_________________
Age: ________ Grade:________
IMMUNIZATIONS / HEALTH HISTORY
Immunizations & date given since last Health Appraisal:
_______
Immunization record attached
Sickle Cell Screen: Positive Negative Not done Date:
No immunizations given today
PPD:
Positive Negative
Not done Date:
_______
Elevated Lead: Yes No Not done Date:
_______
Dental Referral
Yes
No
Date:
Providers Name ______________
_______
Significant Medical/Surgical History:
See attached
Specify current diseases
:
Asthma
Diabetes:
Type 1
Type 2
Hyperlipidemia
Hypertension
Other
________
Allergies:
None LIFE THREATENING_____________________ Food_________________________
Insect____________
Seasonal
_______ Medication
__________
Other____________
PHYSICAL EXAM
Height: ______________Weight: _____________ Blood Pressure: ____________
th
Body Mass Index:
Weight Status Category (BMI Percentile):
less than 5
th
th
th
th
5
through 49
50
through 84
85th through 94th
95th through 98th 99th and higher
Vision-Far
R 20/__________ L 20/__________
With correction R 20/__________ L 20/__________
Vision-Near R 20/__________ L 20/__________
With correction R 20/__________ L 20/__________
Hearing
Pass 20 db sc both ears or R_______L_______ Scoliosis:
Negative
Positive
:__________
EXAM ENTIRELY NORMAL
Referral________________________
Tanner: I
II
III
IV
V
Specify any abnormality (use reverse of form if needed):
MEDICATIONS
Medications (list all): None
Additional medications listed on reverse of form
Medication Orders for School Attached
Name: ___________________________________________ Dosage/Time:
Name: ___________________________________________ Dosage/Time:
If AM dose is missed at home:
**Please advise parent to bring in additional medication(s) in the event morning dose not given or emergency
sheltering in school is needed.
PHYSICAL EDUCATION / PLAYGROUND / CSE CONSIDERATION
Free from contagions & physically qualified for all physical education, playground and school activities
May participate only as checked below:
Limited contact: Gymnastics, volleyball, track & field, baseball, floor hockey, softball, soccer, football, basketball,
playground, adventure activities.
Non-contact: Bowling, swimming, dancing, running, walking, jump rope, calisthenics, plyometrics, scooter activity.
Specify medical accommodations needed for school:
_____________________ None
Known or suspected disability:
______
Restrictions:
______
Protective equipment required:
Glasses/sport eyewear
Other:
______________
Provider’s Signature & Stamp:
Date: _____________
Provider’s Address & Phone Number: _______________________________________________________________
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. 01/08
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