Required NYS School Health Examination Form



REQUIRED NYS SCHOOL HEALTH EXAMINATION FORMTO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTORNote: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually forinterscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or Committee on Pre-School Special education (CPSE).STUDENT INFORMATIONName:Sex: ? M ? FDOB:School:Grade:Exam Date:HEALTH HISTORYAllergies? NoYes, indicate typeMedication/Treatment Order Attached? Anaphylaxis Care Plan AttachedFood? Insects? Latex? Medication? Environmental54561991733156581025017331569531412507640261640275104895867341617131279530540640217386805406402360850154064024067657540640237800025157470421149751574704808956515747054672615157470612004151574706794944515747016833726418770228635564187701694433660685722863556601320Seizure Care Plan AttachedDate of last seizure: Medication/Treatment Order AttachedType: Seizures? NoYes, indicate typeIntermittent? Persistent? Other : Asthma Care Plan AttachedMedication/Treatment Order AttachedAsthma? NoYes, indicate typeDiabetes? NoYes, indicate typeMedication/Treatment Order Attached? Diabetes Medical Mgmt. Plan AttachedType 1 ? Type 2? HgbA1c results:Date Drawn: Risk Factors for Diabetes or Pre-Diabetes:Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.BMI kg/m2 Percentile (Weight Status Category): ? <5th ? 5th-49th ? 50th-84th ? 85th-94th ? 95th-98th ? 99th and<Hyperlipidemia:NoYesHypertension:NoYesPHYSICAL EXAMINATION/ASSESSMENTHeight:Weight:BP:Pulse:Respirations:TESTSPositiveNegativeDateOther Pertinent Medical ConcernsPPD/ PRN??One Functioning:? Eye? Kidney? TesticleConcussion – Last Occurrence: Mental Health: Other:Sickle Cell Screen/PRN??Lead Level Required Grades Pre- K & KDateTest Done? Lead Elevated > 10 ?g/dLSystem Review and Exam Entirely NormalCheck Any Assessment Boxes Outside Normal Limits And Note Below Under AbnormalitiesHEENTDentalNeckLymph nodesCardiovascularLungsAbdomenBack/SpineGenitourinaryExtremitiesSkinNeurologicalSpeechSocial EmotionalMusculoskeletalAssessment/Abnormalities Noted/Recommendations:Additional Information AttachedDiagnoses/Problems (list)ICD-10 CodeName:DOB:SCREENINGSVisionRightLeftReferralNotesDistance Acuity20/20/Yes ? NoDistance Acuity With Lenses20/20/Vision – Near Vision20/20/Vision – Color? Pass ? FailHearingRight dBLeft dBReferralPure Tone ScreeningYes ? NoScoliosis Required for boys grade 9NegativePositiveReferralAnd girls grades 5 & 7??Yes ? NoDeviation Degree:Trunk Rotation Angle:Recommendations:RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORKFull Activity without restrictions including Physical Education and Athletics.Restrictions/AdaptationsUse the Interscholastic Sports Categories (below) for Restrictions or modificationsNo Contact SportsIncludes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestlingNo Non-Contact SportsIncludes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle,Skiing, swimming and diving, tennis, and track & fieldOther Restrictions:Developmental Stage for Athletic Placement Process ONLYGrades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sportsStudent is at Tanner Stage: ? I ? II ? III ? IV ? VAccommodations: Use additional space below to explainBrace*/OrthoticColostomy Appliance*Hearing AidsInsulin Pump/Insulin Sensor*Medical/Prosthetic Device*Pacemaker/Defibrillator*Protective EquipmentSport Safety GogglesOther:*Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.Explain: MEDICATIONSOrder Form for Medication(s) Needed at School attachedList medications taken at home:IMMUNIZATIONSRecord Attached? Reported in NYSIISReceived Today: ? Yes ? NoHEALTH CARE PROVIDERMedical Provider Signature:Date:Provider Name: (please print)Stamp:Provider Address:Phone:Fax:Please Return This Form To Your Child’s School When Entirely Completed.437192412242164831079122421643829852247633482554222420962789770266252937357432662529438298526625294825542266252913846421849323182166218493235437733503396538241369148379824438906327982444233621798244458767123361395146408264040651519322972320515193233484945151932369148351519326092380777410165459987774101 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download