Physicians Report Of Physical Examination printable pdf download

Health Services

725 Harrison Street

Syracuse, New York 13210

Ph. (315) 435-4145

PHYSICIAN’S REPORT OF PHYSICAL EXAMINATION

Fax (315) 435-4859

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)

Name: ____________________________________________________________ Date of Birth: ________________________________________

1 M

1 F

School: ____________________________ Gender:

Grade: ___________ Date of Physical Examination: _________________

IMMUNIZATIONS/HEALTH HISTORY

1 Immunization record attached

Sickle Cell Screen: 1 Positive 1 Negative 1 Not done Date: _____________

1 No immunization given today

1 Positive 1 Negative 1 Not done Date: _____________

PPD:

1 Immunizations given since last Health Appraisal:

1 Positive 1 Negative 1 Not done Date: _____________

Elevated Lead:

1 Positive 1Negative 1 Not done Date: _____________

Dental Referral:

1 See attached _______________________________________________________________________

Significant Medical/Surgical History:

1Asthma

Diabetes: 1 Type 1 1 Type 2

1Hyperlipidemia

1 Hypertension

Specify Current diseases:

1 Other ________________________________________________________________

1 LIFE THREATENING 1 Food: _______________ 1 Insect: _______________ 1 Other: _______________

Allergies:

1 Seasonal

1 Medication: ____________________________ _____________________________

PHYSICAL EXAM

Height: ________________ Weight: ______________ Blood Pressure: _____________ Date of Exam: ____________________

Referral

Body Mass Index: _____ _____ . _____

Vision – without glasses/contact lenses

Weight Status Category (BMI Percentile):

Vision – with glasses/contact lenses

1less than 5

1 5

1 50

Vision – Near Point

– 49

– 84

185

195

1 99

Hearing 1 Pass 20 db sc both ears or:

– 94

– 98

+ higher

1 EXAM ENTIRELY NORMAL

Scoliosis: 1 Negative 1 Positive: _____________

Tanner: I.

11. 111. 1V. V.

Specify any abnormality _______________________________________________________________________________________

MEDICATIONS

Medications (list all): 1 None

1 Additional medications ________________________________________________________

Name: _____________________________________________ Dosage/Time: ____________________________________________

Duration of Med order*:

school year

other, please specify: ______________________________________________________

Reason for Med order/Diagnosis*

______________________________________________________________________

I assess this student to be self-directed 1 Yes 1 No

Student may self carry and self administer medication 1 Yes 1 No

Student may self carry and self administer medication on a field trip 1 Yes 1 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.

PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK QUALIFICATION/CSE CONSIDERATION

1 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, archery, weight train, crew, dance, track, run, walk, rope jump

1 Specify medical accommodations needed for school: _________________________________________ 1 None

1 Known or suspected disability: ___________________________________________________________________________

1 Restriction: ____________________________________________________________________________________________

1Protective equipment required: 1 Athletic Cup 1 Sport goggles/impact resistant eyewear 1 Other: ________________

Provider’s Signature: _________________________________________________ NYS License #*___________________________

Provider’s Name/Address: _____________________________________________ Phone: ______________Fax: _______________

*Required

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.

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Physicians Report Of Physical Examination

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