Health Appraisal Form printable pdf download

NYSED 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).

HICKSVILLE SCHOOLS HEALTH APPRAISAL FORM

Name:

Date of Birth:

 M

 F

School: _______________________________________________________

Gender:

Grade: ______________

HEALTH HISTORY

(Parent Circle Yes or No)

1. Has your child ever had any fractures, dislocations, severe sprains or serious injuries?

Yes

2. Has your child ever been hospitalized or treated in an emergency room?

Yes

3. Has your child ever had surgery?

Yes

4. Has your child any allergies ___ Seasonal; ___ Life threatening; ___ Asthma; ___ Medication

Yes

5. Does your child take any medication now?

Yes

6. Has your child ever experienced any type of head injury or concussion?

Yes

7. Has your child had any chronic disease?

Yes

8. Does your child have a heart murmur, high blood pressure extra heartbeat or any heart abnormality?

Yes

IF YOU HAVE ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN BELOW:

______________________________________________________________________________________________________________

To the best of my knowledge, the above information is correct:

Parent/Guardian Signature______________________________________________________________

Date: ___________________

PHYSICAL EXAM TO BE COMPLETED BY PHYSICIAN



Immunization record attached

Elevated Lead:

Yes

Not done Date:



No immunizations given today

Dental Referral

Yes

Not done Date:



Immunizations given since last Health Appraisal:

_________



Significant Medical/Surgical History:

See attached



 Asthma

Diabetes:  Type 1  Type 2

Specify current diseases:

Hyperlipidemia

Hypertension

 Other:



Allergies:

LIFE THREATENING

Food:

___

Insect:

Other: ______________



Seasonal

Medication: ___________________________________________________________________

Height:

Blood Pressure:

Pulse:

Weight:

Abdomen:

Eyes:

Hernia:

Ears:

Heart:

Vision:

Lungs:

Nose & Throat:

Orthopedic:

Mouth & Teeth:

Scoliosis:

Skin:

Other:

Student requires medication? Yes ___ No ___. If yes, please specify:

Student may carry inhaler and self-administer: Yes ___ No ___ I assess this student to be self-directed: Yes ___ No ___

Referral

Vision - without glasses/contact lenses

____ ____ . ____

Body Mass Index:

Weight Status Category (BMI Percentile):

Vision - with glasses/contact lenses

 less than 5

 5

 50

through 49

through 84

Vision - Near Point

 85

 95

 99

Hearing  Pass 20 db sc both ears or:

through 94

through 98

and higher

 Free from contagions & physically qualified for all physical education, sports, playground, work & school activities

Provider’s Stamp below:

Provider’s Signature:

Actual Date of Examination: _____________________________

(OVER ---------- )

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. 10/3/07

Health Appraisal Form

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