Cortland Enlargedcityschool District Healthappraisalform
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1Date of Exam:__________________________
NYSED required 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
CORTLAND ENLARGED CITY SCHOOL DISTRICT
HEALTH APPRAISAL FORM
Name:____________________________________________
Date of Birth:_____________________________
School: ___________________________________________
Gender:
M
F
Grade: _________
IMMUNIZATIONS / HEALH HISTORY
Immunization record attached
Sickle Cell Screen:
Positive
Negative
Not done Date: _______
No immunizations given today
PPD:
Positive
Negative
Not done Date: _______
Immunizations given since last Health Appraisal
Elevated lead:
Yes
No
Not done Date: _______
Immunizations up to date
Dental Referral
Yes
No
Not done Date: _______
Significant Medical / Surgical History:
See attached
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Specify current diseases:
Asthma
Diabetes
Type 1
Type 2
Hyperlipidemia
Hypertension
Other: _______________________________________________________________________
Allergies:
LIFE THREATENING
Food:___________
Insect:_____________
Other:______________________________
Seasonal
Medication: _______________________________________________
PHYSICAL EXAM
Height:___________
Weight: ____________ Blood Pressure: ____________
U/A:________________________
Referral
Body Mass Index: _____ _____ _____
Vision – without glasses/contact lenses
R
L
Weight Status Category (BMI Percentile):
Color: ____________ Hyperopia: ________
th
th
th
th
th
less than 5
5
through 49
50
through 84
Vision – with glasses/contact lenses
R
L
th
th
th
th
th
85
through 94
95
through 98
99
and higher
Vision – Near Point
R
L
Hearing
Pass 20 db sc both ears or:
R
L
Pertinent Heath Information:
Immunizations:
Skin and Hair
______________ Tanner stage: I. II.
DPT _____ _____ _____ _____ _____
Eyes and Eyelids
______________ III.
IV.
V.
OPV _____ _____ _____ _____ _____
Ears and Eardrums
______________
Measles ______ Mumps_______Rubella_____
Nose and Throat
______________
MMR ____ ______ PROQUAD___________
Teeth
Gums
______________
TB Tine test _______ Results _____________
and
Thyroid
Lymph Nodes______________
HIB _____ _____ _____ _____
and
Chest and Heart
______________
HEP B _______ _______ ________
Abdomen
______________
HEP A _______ ________
External Genitalia
______________
Tdap _____________ Td __________
Bones and Joints
______________
Pediatrix __________ __________
Scoliosis
______________
Gardasil ______ ______ ______
Feet
______________
Meningococcal ______ ______ ______
Other Observations: ________________________________________ Varicella _________ _______________
EXAM ENTIRELY NORMAL
Scoliosis:
Negative
Positive :____________
Specify any abnormality (use reverse of form if needed):_____________________________________________________________________________
___________________________________________________________________________________________________________________________
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
Free from contagious & physically qualified for all physical education, sports, playground, work & school activities OR only as
checked:
___ Limited contact: cheerlead, gymnastics, ski, volleyball, crosscountry, handball, fence, baseball, floor hockey, softball.
___ Noncontact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weigh train, crew, dance, track, run, walk, rope jump.
Specify medical accommodations needed for school: _____________________________________________
None
Known or suspected disability: ______________________________________________________________
Please monitor
Restrictions: _____________________________________________________________________________
Please monitor
Protective equipment required:
Athletic Cup
Sport goggles/impact resistant eyewear
Other: ___________________
(Stamp below)
Provider’s Signature: ________________________________________
Phone: __________________________
Provider’s Name/Address: ____________________________________
Fax: ____________________________
Parent’s Signature: __________________________________________
Date: ____________________________
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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