NYC Medical Form
NEW ADMISSION EXAMINATION FORM
DEPT. OF HEALTH & MENTAL HYGIENE -- DEPT. OF EDUCATION
Return in 2 Weeks. Please Print Clearly / Press Hard
TO BE COMPLETED BY THE PARENT OR GUARDIAN
STUDENT LAST NAME
FIRST NAME
MIDDLE
PARENT GUARDIAN FOSTER PARENT
LAST NAME
DISTRICT SCHOOL
NUMBER
FIRST NAME
STUDENT ADDRESS
Public Elem Public JHS/IS
Public H.S. Non-Public
SCHOOL NAME:
HEALTH MESSAGE
STUDENT ID # / OSIS
See Reverse Side
SEX
Male Female
BIRTHDAY MONTH DAY YEAR
RACE/ETHNICITY
Check all that apply
Hispanic Asian Black American Indian White Other
APT/FL ZIP
TELEPHONE NO.
HOME: (
)
WORK: (
)
Annex 1 Annex 2
Does this child have any form of health insurance, Yes
including Medicaid or Child Health Plus?
No
TO BE COMPLETED BY THE HEALTH CARE PROVIDER
Does the student have a past or present medical history of the following:
PRES. PAST NO
PRES. PAST NO
ASTHMA (If present, attach
medication administration form)
Diabetes (If present attach
medication administration form)
Allergies
Congenital Heart Disease Seizures
Cancer Orthopedic Problems Vision Problems Hearing Problems
PRES. PAST NO
Speech Problems Hospitalizations
Surgery Serious Illness Serious Accidents Other Problems/Limitations
If yes to any item, provide:
DATE
DETAILS
PHYSICAL EXAMINATION: HEIGHT
( / ) in
o o ile WEIGHT
lb ( o/o ile) BMI
( / ) o o ile BLOOD PRESSURE
/
GENERAL APPEARANCE (NUTRITIONAL STATUS):
NL AB
HEENT DENTAL STATUS NECK
NL AB
LYMPH NODES LUNGS CARDIOVASCULAR
DESCRIBE ABNORMALITIES:
NL AB
ABDOMEN GENITO URINARY EXTREMITIES
NL AB
BACK SKIN NEURO
NL AB
GROSS MOTOR PSYCHO/SOCIAL DEV. LANGUAGE BEHAVIORAL FINE MOTOR
Hearing
AUDIO/SWEEP THRESHOLD
DATE
RESULTS
P F P F
Vision
DATE
/ /
FAR
Right
/
Left
/
Both
/
NEAR
/ / /
FUSION COLOR
TB: Only required for students newly entering the NYC school system in Intermediate/Middle/Junior or High School
TB: MANTOUX
(PPD) IMPLANTED READ
DATE
RESULTS
NEGATIVE
MM
POSITIVE
MM
BLOOD-BASED TB TEST RESULTS Name ____________________ POS Date _____________________ NEG
DATE RESULTS
LEAD:
Risk Assessment
DATE DONE / /
RESULTS No Risk At Risk
lIf at risk,
do venous lead screening
P F P F
Note: Screening for Amblyopia requires separate distance acuity measurements in each eye and a fusion test.
Chest X-ray / /
Normal Abnormal Not Indicated
DATE DONE
/ /
BCG / /
YES NO
On INH / /
YES NO
RESULTS
.
IMMUNIZATION -- DATES
Citywide Immunization Registry no.
DPT/DTaP or DT or Td IPV/OPV
Hepatitis B HIB
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / /
MMR VZV
/ / / / / / / /
/ / / / / / / /
Other
/ /
/ /
May provide copy of CIR print out in lieu of completing this section. Must complete CIR Number above.
DIAGNOSES -- If Asthma, indicate severity
Well Child V202
ICD CODE
1.
DATE OF
EXAM:
MONTH
DAY
Physician Signature
YEAR
DOH ONLY
PROVIDER I.D.
TYPE OF EXAMINATION: NAE Current
NAE Prior Year/s
2.
Comments
3. RECOMMENDATIONS/REFERRALS
FULL PHYSICAL ACTIVITY
RESTRICTIONS
Specify limitations and/or special alerts (i.e. allergies, medications, precautions)
Physician Name (Print) Address Telephone
________________________________________
________________________________________
________________________________________
Date
I.D. NUMBER
Reviewed:
/ /
Name of facility
REVIEWER:
211S (REV. 2/07)
Type of facility
HHC Child Health Clinic HHC Communicare Clinic HHC Hosp. Clinic
Private Practice Comm. Health Center Vol. Hosp. Clinic
Copies: White (Medical Room), Canary (Region)
School-Based Clinic OTHER SHP in School
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