Health Appraisal Form Page 2
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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
triennially for the Committee on Special Education (CSE).
IMMUNIZATION RECORD TO BE COMPLETED BY PHYSICIAN
Immunizations
Date
Date
Date
Date
Date
Date
st
nd
rd
st
nd
rd
1
dose
2
dose
3
dose
1
booster
2
booster
3
booster
Polio
DPT
TD or DT
Tdap
MMR
Measles
Mumps
Rubella
Hib
Hepatitis B
Varicella
Pneumococcal
Meningococcal
PPD (Tuberculin)
Hepatitis A
Lead
Other
Legal requirement for immunization waived because of: Religious exemption _______________ Medical exemption ____________
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
DISPOSITION: Full Unlimited Participation _____________ in all sports listed below:
May the student participate in the following interscholastic sports?
Contact Sports:
Yes ____ No ____
(Football, Lacrosse (boys), Wrestling)
Limited Contact Sports:
Yes ____ No ____
(Basketball, Baseball, Gymnastics, Lacrosse (girls), Soccer, Softball, Cheerleading, Kickline)
Non-Contact Sports:
Yes ____ No ____
(Cross Country, Swimming, Tennis, Track & Field, Weight Training, Volleyball)
Moderately Strenuous Sports:
Yes ____ No ____
(Bowling, Golf)
Specify medical accommodations needed for school:
None
Please monitor
Known or suspected disability:
Please monitor
Restrictions:
Athletic Cup
Sport goggles/impact resistant eyewear
Other:
Protective equipment required:
Rev. 3/08
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
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