M.d.health Appraisal Form
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1MD HEALTH APPRAISAL FORM
Name: _________________________________ Date of Birth ____________________________
Address:__________________________________________________________Phone: ________
IMMUNIZATIONS/SCREENING
___ Immunizations given since last Health Appraisal
___ None given today
___ Immunization record attached
*-required for entry to school in NYS – requirements may vary by age & grade
st
nd
rd
th
th
1
2
3
4
5
SICKLE CELL SCREEN
Date:
DTaP
>
*
*
Positive
Negative
Polio:type
>
*
*
*if IPV
PPD
Date:
HIB
Positive
Negative
Latest tetanus
LEAD SCREEN
Date:
Hep B
*
*
*
Positive
Negative
MMR
*
*
Varivax
>
-Disease
Vision – without glasses/contact lenses
R
L
Pneumococcal
Vision-with glasses/contact lenses
R
L
Vision-Near Point
R
L
Hearing
R
L
1. Significant Medical /Surgical History: _______________________________________________________
_____________________________________________________________________________________________
2. Allergies: __________________________________________________________________________________
_____________________________________________________________________________________________
3. Medication taken regularly: _________________________________________________________________
_____________________________________________________________________________________________
PHYSICAL EXAM
Height: ______________
Weight: __________
B.P. _____________ Resting Pulse: __________
___ Check here if entire exam normal
Normal
Abnormal
Comments
General appearance
Nutrition
1-5 1=Cachectic, 3=WNL, 5=Obese
Skin
Head
Eyes
Nose, Throat, Teeth
Lymph Nodes
Lungs
Heart
Abdomen
Genitalia
Tanner – I. II. III. IV. V.
Musuloskeletal
Scoliosis:
Negative
Positive
Neurological
4. Medication:
___ None
___ Medication at home only
___ Medication to be given at school
Name: _______________________________________________________________________________________
Dosage/Time: _________________________________________________________________________________
If AM Dose is missed at home: ____________________________________________________________________
PHYSICAL EDUCATION/SPORTS/PLAYGROUND
___ Physically qualified for sports or full playground as indicated below.
___ Contact/Collision: Basketball, Soccer, Jumping
___ Non-contact/strenuous: Cheerleading, Gymnastics, Volleyball, Running
___ Non-strenuous: Badminton, Golf, Table Tennis, Tennis
___ Known or suspected disability: _____________________________________________________________
___ Restrictions ______________________________________________________________________________
Provider’s Signature ______________________________________________ Date of PE: ____________________
Providers Name: _________________________________________________ Date: _____________________
Provider’s address ________________________________________________ Phone: ____________________
Jul-05
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Parent category: Medical