Physician'S Health Appraisal Form
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2NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10,
Interscholastic athletics, working permits, and triennially for the Committee on Special Education (CSE).
A dental health certificate is also requested.
PHYSICIAN’S HEALTH APPRAISAL FORM
Chappaqua Central School District
Name: _________________________________________________ Date of Birth: ________________ Gender:
M
F
School: ________________________________________________ Grade: _____ Home Phone: _______________________
Work: (______) ___________________ Cell / Contact Phone: (______) _______________
IMMUNIZATIONS/HEALTH HISTORY
Immunization record attached
TB testing:
Low Risk/not indicated
PPD Date: ________________
Positive
Negative
SIGNIFICANT MEDICAL / SURGICAL HISTORY
None
See attached
Other (specify below)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Allergies
No
Yes
If yes:
Food
Insect
Latex
Medication
Other: ____________
Specify: _____________________________________________________________________________________________
LIFE THREATENING (Specify: _______________________________)
Benadryl prescribed
EpiPen prescribed
Medication Administration forms for Benadryl and EpiPen must be completed by physician and attached.
PHYSICAL EXAMINATION
Height: _______________ Weight: _________________ Blood Pressure: ________________ Pulse: ________________
Referral
Vision — without glasses/contact lenses
R
L
%
Body Mass Index: (Required): ________
Age____
Vision — with glasses/contact lenses
R
L
Weight Status Category
(Required):
(BMI Percentile)
:
%
%
Hearing
Pass 20 db sc both ears or:
R
L
Male____________
Female _____________
EXAM ENTIRELY NORMAL
Tanner : I II
III
IV
V
Scoliosis:
Negative
Positive: __________________
Specify any abnormality: __________________________________________________________________________________
______________________________________________________________________________________________________
MEDICATIONS
Medications (list below) :
None
1. _________________________________________________ 3. _______________________________________________
2. _________________________________________________ 4. _______________________________________________
PHYSICAL EDUCATION / SPORTS/ PLAYGROUND
Full participation in all physical education, sports, playground, work & school activities
Limited participation
Specify: _________________________________________________________________________
Physician’s Signature:
_______________________________________________
Date of exam: __________________
Provider’s Name / Address: _______________________________________________
Phone: _______________________
Provider’s Stamp: (required)
Parents of students participating in sports must complete the reverse side.
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