Canandaigua City School District Health Appraisal Form printable pdf download

NYSED requires an annual physical exam for new entrants, students in Grades UPK, K, 2, 4, 7 and 10, sports, working permits and

triennially for the Committee on Special Education (CSE).

Canandaigua City School District HEALTH APPRAISAL FORM

TO BE COMPLETED BY PHYSICIAN

Name: ________________________________________________

Date of Birth: ____________________

Age: ______ years ______ months

Gender: Female: ________

Male: __________

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

Not done Date:

Dental Referral

Yes

Not done Date:

Significant Medical/Surgical History:

See attached

Known or suspected disability:

Please monitor

Specify current diseases:

Ì Asthma

Diabetes: Ì Type 1 Ì Type 2

Hyperlipidemia

Hypertension

Ì Other:

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:

Weight Status Category (BMI Percentile):

Vision - with glasses/contact lenses

less than 5

through 49

through 84

Vision - Near Point

through 94

through 98

and higher

Hearing

Pass 20 db sc both ears or:

Ì EXAM ENTIRELY NORMAL

Tanner:

II.

III.

IV.

Scoliosis:

Negative

Positive:

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

MEDICATIONS

Medications to be given at school (list all):

None

Additional medications listed on reverse of form

Name: ____________________________________________________ Dosage/Time: _________________________________________________

Medications to be given at school with notice from parent that AM dose was missed at home:

Name: ____________________________________________

Dosage/Time: _________________________________________________

I assess this student to be self-directed and student may self carry and self administer medication Ì Yes

Ì 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.

Medications given at home: (List)______________________________________________________________________________________________

PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

1. Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as

checked:

___ 2. Limited contact: cheerleading, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.

___ 3. 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

Restrictions:

Please monitor

Protective equipment required:

Athletic Cup

Sport goggles/impact resistant eyewear

Other:

(Stamp below)

Provider’s Signature:

Phone:

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. 8/17/2009

Canandaigua City School District Health Appraisal Form

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