Au Sable Valley Central School Health Certificate / Appraisal Form
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2AU SABLE VALLEY CENTRAL SCHOOL
HEALTH CERTIFICATE / APPRAISAL FORM
Name
Date of Birth
:
:
School Year 2013-2014
M F
School
Gender
Grade:
:____________________________________
:
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:
Dental Referral
Yes
No
Not done Date:
Significant Medical/Surgical History:
Allergies:
LIFE THREATENING
Food:
Insect:
Other:
Seasonal
Medication:
PHYSICAL EXAM
Height: _____________ Weight: _____________ Blood Pressure: ____________ Pulse:__________
Date of Exam:
Referral
Vision - without glasses/contact lenses
____ ____ . ____
Body Mass Index:
R
L
Weight Status Category (BMI Percentile):
Vision - with glasses/contact lenses
R
L
less than 5
th
5
th
th
50
th
th
through 49
through 84
Vision - Near Point
R
L
85
th
th
95
th
th
99
th
Hearing Pass 20 db sc both ears or:
through 94
through 98
and higher
R
L
EXAM ENTIRELY NORMAL
Tanner:
I.
II.
III.
IV.
V.
Scoliosis:
Negative
Positive:
Specify any abnormal findings :
MEDICATIONS
Medications (list all):
None
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, play ground, work & school activities OR only as checked:
___ Contact: cheerlead, ski, volleyball, handball, fence, baseball, hockey, softball, football, basketball, soccer and wrestling.
___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, gymnastics, weight train, dance, cross country, track/field, run and walk.
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:
OPTIONAL INFORMATION, if known
Asthma
Diabetes: Type 1 Type 2
Specify current diseases:
Hyperlipidemia
Hypertension
Other:
By signing this form, I consent to my child’s physical exam and for the release of medical information to the
school and/or the health care provider.
Parent/Guardian Signature
_________________________________ Date:__________
For Office Use ONLY:
Provider’s Signature
:_______________________________ _______ Date:__________
School Physician’s Signature
Date
Provider’s Name
:___________________________________________
Address: __________________________________________
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