Nysed Health Certificate/appraisal Form - West Irondequoit Central School District
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2WEST IRONDEQUOIT CENTRAL SCHOOL DISTRICT
NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and
triennially for the Committee on Special Education (CSE).
HEALTH APPRAISAL FORM
Name: ___________________________________________ Gender: M F Date of Birth:______________________
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:
See attached
Asthma
Diabetes: Type 1 Type 2
Specify current diseases:
Hyperlipidemia
Hypertension
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:
R
L
Weight Status Category (BMI Percentile):
Vision - with glasses/contact lenses
R
L
th
th
th
th
th
less than 5
5
50
through 49
through 84
Vision - Near Point
R
L
th
th
th
th
th
85
95
99
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 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: cheerleading, gymnastics, skiing, 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.
___________________________
SLP
OT
PT
Specify medical accommodations needed for school:
None
Other
________________________________________________________________
Known or suspected disability:
None
_____________________________________________________________________________
Restrictions:
None
Protective equipment required:
Athletic Cup
Sport Goggles/Impact Resistant Eyewear
Other
Provider’s Signature:
Phone:_______________________ Fax:__________________
Provider’s Name: _________________________________________
Address: ___________________________________________
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. 8/2010
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