City School District Of New Rochelle Health Appraisal Form
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2NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and
Annual & Program Reviews and Reevaluations for the Committee on Special Education (CSE)
! ! ! !
***
PARENTS
PARENTS
PARENTS
PARENTS
PLEASE SIGN AND DAT
PLEASE SIGN AND DATE BOTH SIDES OF THIS
PLEASE SIGN AND DAT
PLEASE SIGN AND DAT
E BOTH SIDES OF THIS
E BOTH SIDES OF THIS
E BOTH SIDES OF THIS FORM
FORM
FORM
FORM
CITY SCHOOL DISTRICT OF NEW ROCHELLE
HEALTH APPRAISAL FORM
Date of Exam
: ____/____/____
Name:
Date of Birth: ____/____/____ Gender:
M
F
Iona Preparatory School K-12
School: ____________________________________________________________
Grade: _____
IMMUNIZATIONS / HEALTH HISTORY
Immunization record attached
Sickle Cell Screen:
Positive
Negative
Not done Date:
No immunizations given today
PPD:
Please complete screening on reverse side of form
Immunizations given since last Health Appraisal: (include dates)
Elevated Lead:
Yes
No
Not done Date:
Dental Referral
Yes
No
Not done Date:
Significant Medical/Surgical History:
See attached
Specify current diseases:
Asthma
Diabetes:
Type 1
Type 2
Hyperlipidemia
Hypertension
Other:
Allergies:
LIFE THREATENING
Food:
Insect:
Other:
Seasonal
Medication:
PHYSICAL EXAM
Height: _______________
Weight: _______________
Blood Pressure: _______________
Date of Exam:
Referral
Vision - without glasses/contact lenses
____ ____ . ____
Body Mass Index:
(Required by NYS)
R
L
Weight Status Category (BMI Percentile):
Vision - with glasses/contact lenses
R
L
th
th
th
th
th
Vision - Near Point
R
L
less than 5
5
through 49
50
through 84
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:
For Girls: Age of onset of menses: ________________
LMP: ________________
Specify any abnormality (use separate paper if needed):
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:
SPORTS CLEARANCE : By signing and submitting this form, the parent and physician attest that they have fully disclosed
all of this student’s health history, conditions, medications and relevant family history (e.g., early cardiac death.) Parent
and physician assume liability for non-disclosures of such information. The School District Physician has final authority to
medically clear students for interscholastic sports participation.
Provider’s Signature:
Phone:
Provider’s Name/Address:
Fax:
***Parent Signature:
Date:
H-1 HEALTH APPRAISAL FORM (Revised 2/08)
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.
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