SHENENDEHOWA      Health Appraisal/Sports Physical Examination Form Grades K-12

Students in kindergarten, 2nd, 4th, 7th & 10th grades and all new students are required by Education Law to have a physical. Physicals may be done no earlier than 12 months prior to entrance to school.
 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:                      
Significant Medical/Surgical History:          See attached
                                                                                                                                                                                                                                                                                                                                                                                                                               
Allergies:           LIFE THREATENING ____ Food ____ Insect  ____ Other: ___ Seasonal Medication:____

PHYSICAL EXAM
       Check here if entire exam normal Height                Weight               Blood Pressure               Date of Exam              
  Referral
Body Mass Index _____ _____._____ Vision - without glasses/contact lenses R L  
Weight Status Category (BMI Percentile) Vision - with glasses/contact lenses R L  
    less than 5th     5th through 49th     50th through 84th Hearing  q Pass 20 db sc both ears or:     R L  
    85th through 94th     95th through 98th     99th and higher        
Check (√) Equals Normal Finding  
General Appearance: Eyes:
Skin: Ears:
Head: Lungs:
Nose, Throat, Teeth: Heart:
Lymph Node/Thyroid: Abdomen:
Genitalia: Tanner:     I. ____ II. ____ III. ____ IV. ____ V. ____
Musculoskeletal: Scoliosis:  _____ Negative     ______Positive:
Neurological:  

PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
      Medical Clearance:  Free from contagions & physically qualified for all physical education, sports (includes all contact/collision, etc), playground, work & school activities OR only as checked: 
             ___  Limited contact:  cheerlead, gymnastics, ski(Alpine &XC), volleyball, diving, fence, baseball, floor hockey, softball, basketball,
                      handball.
             ___  Strenuous/Noncontact:  indoor track, cross country, tennis, track & field, swimming, rope jump, weight train
             ___  Non-contact:  badminton, bowl, golf, archery, riflery, dance, walking.

       Specify medical accommodations needed for school:                                                                       None          
___Known or suspected disability:                                                                                                                                              
___Restrictions:                                                                                                                                                                                
____Protective equipment required:       Athletic Cup       Sport goggles/impact resistant eyewear     Other:                                   _

OPTIONAL INFORMATION, if known
Specify current diseases:               Asthma          Diabetes:       Type 1       Type 2                Hyperlipidemia                  Hypertension
          Other:

Provider’s Signature:                                                                                        Phone:                                                             (Stamp below)
 Provider’s Name/Address:                                                                                        Fax:                                           
The school nurse has permission to share information with staff who work with my child.
Parent Signature:                                                                                                          Date:                                        

This form complies with NYSED requirements above and is valid for 12 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.

HA1/HPE5 (revised 4/2008)