REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM
TO BE COMPLETED BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR IF AN AREA IS NOT ASSESSED INDICATE NOT DONE
Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or Committee on Pre-School Special education (CPSE
Name
Sex:
DOB
School
Grade
Exam Date

MonthDayYear
Date
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.
Health History
Allergies
Asthma
Seizures
Type:
Date of Last Seizure

MonthDayYear
Date
Diabetes
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)
Hyperlipidemia
Hypertension
PHYSICAL EXAMINATION/ASSESSMENT
Height
Weight
BP
Pulse
Respirations
TB-PRN
Date

MonthDayYear
Date
Sickle Cell Screen-PRN
Date

MonthDayYear
Date
List Other Pertinent Medical Concerns (e.g. concussion, mental health, one functioning organ)
Lead Level Required Grades Pre-K& K
Date

MonthDayYear
Date
Diagnoses/Problems (list) *Required only for students with an IEP receiving Medicaid
Name
DOB
SCREENINGS

Vision (w/correction if prescribed)	Right	Left	Not Done
Distance Acuity	20/	20/
Near Vision Acuity	20/	20/

Referral
Color Perception Screening
Hearing: Passing indicates student can hear 20dB at all frequencies: 500, 1000, 2000, 3000, 4000 Hz; for grades 7 & 11 also test at 6000 & 8000 Hz.
Pure Tone Screening: RIGHT EAR
Pure Tone Screening: LEFT EAR
Referral
Not Done
Scoliosis Screen Boys in grade 9, and girls in grades 5 & 7
Referral
Not Done
RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK
Developmental Stage for Athletic Placement Process ONLY required for students in Grades 7 & 8 who wish to play at the high school interscholastic sports level OR Grades 9-12 who wish to play at the modified interscholastic sports level.
Tanner Stage
Age of First Menses (if applicable)
Other Accommodations*: (e.g. Brace, orthotics, insulin pump, prosthetic, sports goggle, etc.) Use additional space below to explain. *Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.
MEDICATIONS
IMMUNIZATIONS
HEALTH CARE PROVIDER
Medical Provider Signature
Provider Name: (please print)
Provider Address
Phone
Format: (000) 000-0000.
Fax
Please Return This Form To Your Child's School When Completed.
Should be Empty:

Health History