Forestville Central School Health Appraisal Form
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2NYSED requires an annual physical exam for new entrants, students in Grades Pre-K, K, 2, 4, 7 and 10, sports,
working permits and triennially for the committee on Special Education (CSE).
FORESTVILLE CENTRAL SCHOOL HEALTH APPRAISAL FORM
Name: __________________________________________________
Date of Birth: _________________________________
School: _____________________________________________ Gender:
M
F
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:
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: ________ ________ . ________
R
L
Vision - with glasses/contact lenses
Weight Status Category (BMI Percentile):
R
L
‰ less than 5 th
‰ 5 th through 49 th ‰ 50 th through 84 th Vision - Near Point
R
L
‰ 85 th through 94 th ‰ 95 th through 98 th ‰ 99 th 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.
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