Health Appraisal Form

NYSED requires an annual physical exam for new entrants, students in Grades K,2,4,7&10, sports, working permits and triennially for the Committee on Special Education (CSE).

HEALTH APPRAISAL FORM

Name:

Date of Birth:

School: __________________________________________

Grade: ____________________

Gender:

M

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:

❒

Significant Medical/Surgical History:

See attached

❒

❒

Specify current diseases:

❒ Asthma Diabetes: ❒ Type 1

❒ Type 2

Hyperlipidemia

Hypertension

❒ Other:

Does this child have a history of concussion?

Yes

No

If yes, please give date(s) and details: _______________________________________

Does this child have a history of

chest pain

heart disease

lung disease

Is there a family history of sudden death from heart disease at a young age?

Yes

No If yes, please specify ___________________________

❒

❒

❒

❒

Allergies:

LIFE THREATENING

Food:

Insect:

Other:

❒

❒

Seasonal

Medication:

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

through 49

50

through 84

Vision - Near Point

R

L

th

th

th

th

th

85

through 94

95

through 98

99

and higher

Hearing

Pass 20 db sc both ears or:

R

L

❒ EXAM ENTIRELY NORMAL

❒

❒

Tanner:

I.

II.

III.

IV.

V.

Scoliosis:

Negative

Positive:

Specify any abnormality (use reverse of form if needed):

MEDICATIONS

❒

❒

Medications (list all):

None

Additional medications listed on reverse of form

Name: ____________________________________________________ Dosage/Time: _________________________________________________

Name: ____________________________________________________ Dosage/Time: _________________________________________________

If AM dose is missed at home: ________________________________________________________________________________________________

❒

❒

❒

❒

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 / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

❒

Free from contagions & physically qualified for all physical education, sports, playground, 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, riflery, 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:

Athletic Cup

Sport goggles/impact resistant eyewear

Other:

Provider’s Signature:

Phone:

(Stamp below)

Provider’s Name/Address:

Fax:

Parent Signature:

Date:

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. 5/17/12 mkb