Form H.e.104 - Student Health Appraisal
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H.E. 104 (Rev. 10/08)
B U R E A U O F H E A L T H A N D P H Y S I C A L E D U C A T I O N
S T U D E N T H E A L T H A P P R A I S A L
Student Name ________________________________________
Date of Birth______________
Grade _________
School _________________
Immunizations given since last Health Appraisal:
None given today
Immunization record attached
rd
SICKLE CELL SCREEN
Date
1st
2nd
3
4th
5th
*
*
*
DTaP
Positive
Negative
*
Tdap
PPD
Date
*
*
*
**
OPV/IPV/EIPV
Positive
Negative
*
*
*
HIB
LEAD SCREEN
Date
*
*
*
Hep B
Results:
*
Varicella
Disease/Date:
*
*
MMR
Vision—without glasses/contact lenses
R
L
Other
Vision—with glasses/contact lenses
R
L
Vision—Near Point
P
/
/
R
L
LEASE PROVIDE MO
D
YR FOR ALL IMMUNIZATIONS
*Required for entry to school in NYS: Requirements may vary by age/grade
**If IPV
Hearing
R
L
Significant Medical/Surgical History
ee attached ________________________________________________________________________________________
s
Specify Current Disease: Diabetes:
________________
Type 1
Type 2
Asthma
Hyperlipidemia
Hypertension
Other
Allergies:
None
Food
Insect
Seasonal
Medication
LIFE THREATENING ____________________________________________________
P H Y S I C A L E X A M
Check here if entire exam normal
BP ________
Height ________
Weight ________
BMI ________
BMI Percentile ________
th
th
th
th
th
th
th
th
th
Weight Status Category (BMI Percentile):
< 5
5
– 49
50
– 84
85
– 94
95
– 98
>98th
Normal
Abnormal
Comments
Nutrition - BMI
Scale of 1-5: 1=Cachectic (BMI<17.5),
3=WNL (BMI 18.5-24.9),
5=Obese (BMI >29.9)
General Appearance
Extremities
Skin
Head
Eyes
Ears
Nose, Throat, Teeth
Lymph Nodes/Thyroid
Lungs
Heart
Abdomen/Hernia
Genitalia
Tanner -
I.
II.
III.
IV. V.
Musculoskeletal
Scoliosis
Negative
Positive
Neurological
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
Physically qualified for all sports or full playground.
Not qualified for full participation. May ONLY participate in the areas checked below.
Contact/Collision: basketball, diving, field hockey, football, ice hockey, lacrosse, martial arts, soccer, wrestling, team handball, water polo
Limited Contact/Endurance: baseball, cheerleading, cross-country, fencing, field events, floor hockey, gymnastics, handball, skiing, softball,
swimming, track, volleyball
Non-Contact: archery, badminton, bowl, crew, dance, golf, jump rope, rifle team, table tennis, tennis, walking, weights
Knowledge based experience
Physically qualified for employment OR specify accommodation ___________________
_________________
Known or suspected disability
___________________________________
Restrictions
___________________________________
PROVIDER'S SIGNATURE
Date
PROVIDER'S NAME (STAMP) ___________________________________
Phone ___________________
FAX ____________________________
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Parent category: Medical