Nysed Health Certificate / Appraisal Form
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1Recommended
/
Sample Form
NySED regulres an
annuat
physical exam
for
new entrants, sfudents
in
Grades K,
2,
4,
7
and 10, sports, working permits and
triennially
for
the Committee
on
Special
Education
(CSE).
HEALTH CERTIFICATE / APPRAISAL
FORM
Name:
School:
cender:
trtu Or
Date
of Birth:
Grade:
IMMUNTZATIONS / HEALTH HISTORY
D
lmmunization record attached
D
No immunizations given today
D
lmmunizations given since last Health Appraisal:
Sickle Cell Screen
PPD:
Elevated
Lead:
Dental Referral
D
Positive
D
Positive
D
Yes
D
Yes
DNegative
DNegative
LJNo
D
tto
D
Not
done
d
Not
done
fl
Not
done
D
Not
done
Date:
Date:
Date:
Date:
Significant Medical/Surgical
History: D
See attached
Allergies:
D
ttrE
ruRenTENlNG
D
Seasonal
fl Food:
3
Insect:
.
Medication:
lll
other:
PHYSICAL EXAM
Height:
Weight:
Blood Pressure:
Date of Exam
-l
EXAM ENTIRELY
NORMAL
ranner:
I
Speclfy any abnormality (use reverse
of
form if
needed):
Scoliosis:
I
Negative
dPositive:
ilr.
lt.
Body Mass
Index:
_
Weight Status
Category
(BMl Percentile):
fl
less than
5th
E
5'n
through
49'n
fl
50'h
through
84'n
E
85th
through
94h
tr
95rn
through
98'h
tr
99'n
and higher
Vision
-
without glasses/contact lenses
R
L
Vision
-
with glasses/contact lenses
R
L
Vision - Near Point
R
L
Hearing
B
Pass 20 db sc both ears
or:
R
L
MEDICATIONS
Medications
(list all):
E None
D
Addltional medications listed on reverse
of
form
Name:
Name:
Dosage/Time:
Dosage/Time:
lf
AM dose is missed at
home:
I
assess this student to be
self-directed
I Yes
D
t"to
Student
may
self carry and self administer
medication
D
Yes
D
no
shelte
at
school or
if
the
has not
been
aI
;
.
D
I
Free
from
contagions
&
physically qualified for all physical education,
sports,
playground, work
&
school activities
OR
only
as
checked:
Limited
contactt
cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.
Non-contact:
badminton,
bowt,
golf, swim,
tabletennis,
tennis, archery, riflery,
weighttrain,
crew, dance, track,
run,
walk,
rope
jump.
Specify medical accommodations needed for school
I
None
Please monitor
PIease monitor
Known or suspected disabilitY:
I
tr
Restrictions:
Note: Nurse will also assess self-direction for the school
setting.
Please advise parent to send
in
additional medication
in
the event that emergency
Protective
Specify current diseases:
D
Athtetic
cup
D
Sport
resistant
Diabetes:
3Type1
trTYPe2
3
other:
Hyperlipidemia
Hypertension
O
Asthma
O
Other:
Phone
Fax:
(Stamp below)
Provider's Signature
Provider's Name/Address
Date:
Parent Signature:
OPTIONAL INFORMATION,
if
known
This
exam
complies
with
NySED
requirements
above and is
vatid
for
twelve
months,
with the exception of
any
illness or
iniury lasting more than five
days
that witl
require review
by
private heatthcare provider and the school medical
director'
Rev. 2/08
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