Warwick Valley Central School District Health Certificate/appraisal Form
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1Recommended / Sample Form
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).
WARWICK VALLEY CENTRAL SCHOOL DISTRICT
HEALTH CERTIFICATE / APPRAISAL FORM
Name:
Date of Birth:
‰
‰
School Building:
Gender:
M
F
Grade:
IMMUNIZATIONS / HEALTH HISTORY
ˆ
ˆ
ˆ
ˆ
Immunization record attached
Sickle Cell Screen:
Positive
Negative
Not done Date:
ˆ
ˆ
ˆ
ˆ
No immunizations given today
PPD:
Positive
Negative
Not done Date:
ˆ
ˆ
ˆ
ˆ
Immunizations given since last Health Appraisal:
Elevated Lead:
Yes
No
Not done Date:
ˆ
ˆ
ˆ
Dental Referral
Yes
No
Not done Date:
ˆ
Significant Medical/Surgical History:
See attached
ˆ
ˆ
ˆ
ˆ
Allergies:
LIFE THREATENING
Food:
Insect:
Other:
ˆ
ˆ
Seasonal
Medication:
If you have any objection to having this information shared with faculty and/or support staff in the form of a confidential list please sign here.
______________________________ (signature)
PHYSICAL EXAM
Height: _______________
Weight: _______________
Blood Pressure: _______________
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
ˆ EXAM ENTIRELY NORMAL
ˆ
ˆ
Tanner:
I.
II.
III.
IV.
V.
Scoliosis:
Negative
Positive:
Specify any abnormality (use reverse of form if needed):
MEDICATIONS
Please list any medications that this student is taking.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Any medication that is to be given during school hours must have a separate medication authorization form completed by the parent and prescriber.
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
ˆ
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.
ˆ
ˆ
Specify medical accommodations needed for school:
None
ˆ
ˆ
Known or suspected disability:
Please monitor
ˆ
ˆ
Restrictions:
Please monitor
ˆ
ˆ
ˆ
ˆ
Protective equipment required:
Athletic Cup
Sport goggles/impact resistant eyewear
Other:
OPTIONAL INFORMATION, if known
ˆ
ˆ
ˆ Asthma
Diabetes: ˆ Type 1 ˆ Type 2
Specify current diseases:
Hyperlipidemia
Hypertension
ˆ Other:
Provider’s Signature:
Phone:
(Stamp below)
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. 2/08
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