Penfield Central School District Health Appraisal Form
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2NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and for the Committee on Special Education (CSE).
HEALTH APPRAISAL FORM
PENFIELD CENTRAL SCHOOL DISTRICT
Our Lady of Mercy High School
HEALTH OFFICE
1437 Blossom Rd. Rochester, NY 14610
288-7120 X 314 Fax 288-7966
Name: _________________________________________________
Date of Birth: ______________________ Gender:
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:
Dental Referral
Yes
No
Not done Date:
Significant Medical/Surgical History:
See attached
____
Allergies:
LIFE THREATENING
Food:__________
Insect: _____________
Seasonal
Other:
Medication: used for ALLERGIC REACTION: Epi- Pen_____________________________________Benadryl_____________________________
PHYSICAL EXAM
Height: _______________
Weight: _______________
Blood Pressure: _______________
Date of Exam:
Referral
Body Mass Index: ____ ____ . ____
Vision - without glasses/contact lenses
R
L
Weight Status Category (BMI Percentile):
Vision - with glasses/contact lenses
R
L
th
th
th
th
th
less than 5
5
50
through 49
through 84
Vision - Near Point
R
L
th
th
th
th
th
85
95
99
Hearing Pass 20 db sc both ears or:
through 94
through 98
and higher
R
L
EXAM ENTIRELY NORMAL
Scoliosis: Negative Positive:
Tanner:
I.
II.
III.
IV.
V.
Specify any abnormality (use reverse of form if needed):
MEDICATIONS
None
Additional medications listed on reverse of form
Medications (list all):
Name: ____________________________________________________ Dosage/Time: _________________________________________________
Name: ____________________________________________________ Dosage/Time: _________________________________________________
Permission for OTC Pain Medication
to be given by school nurse PRN _________________________________________________________
Acetaminophen ________mg q 4 hours OR
Ibuprofen ________mg q 4 hours OR
Midol _________tabs q 4 hours.
If AM dose is missed at home School Nurse may administer with parent notification.
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.
PHYSICAL EDUCATION / SPORTS/ WORK QUALIFICATION / CSE CONSIDERATION
Free from contagions & physically qualified for all physical education, sports, 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, rifer, 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:
Sport goggles/impact resistant eyewear
Other:
Provider’s Signature:
DATE: _______________
(Stamp below)
Provider’s Name/Address:
Phone: _______________________
Parent Signature (required for any medications given in school)________________________________________________
Date_________________
This exam complies with NYSED requirements and is valid for 12 months; with the exception of any illness or injury lasting more than 5 days that will require review by private healthcare provider.
Rev. 6/2011
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