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REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM
TO BE COMPLETED BY PRIVATE HEALTHCARE 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).
STUDENT INFORMATION
Name:
Affirmed Name
(if applicable)
:
DOB:
Sex Assigned at Birth: Female Male
Gender Identity: Female Male Nonbinary X
School:
Grade:
HEALTH HISTORY
If yes to any diagnoses below, check all that apply and provide additional information.
☐
Allergies
Type:
☐
Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached
☐
Asthma
☐
Intermittent
☐
Persistent
☐
Other:
☐
Medication/Treatment Order Attached
☐
Asthma Care Plan Attached
☐
Seizures
Type:
☐
Medication/Treatment Order Attached
Date of last seizure:
☐
Seizure Care Plan Attached
☐
Diabetes
Type:
☐
1
☐
2
☐
Medication/Treatment Order Attached
☐ Diabetes Medical Mgmt. Plan Attached
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): < 5
th
5
th
- 49
th
50
th
- 84
th
85
th
- 94
th
95
th
- 98
th
99
th
and >
Hyperlipidemia:
☐
Yes
☐
Not Done Hypertension:
☐
Yes
☐
Not Done
PHYSICAL EXAMINATION/ASSESSMENT
Height: Weight:
BP:
Pulse:
Respirations:
Laboratory Testing Positive Negative Date
Lead Level
Required for PreK & K
Date
TB- PRN
☐ ☐
☐ Test Done ☐ Lead Elevated > 5 µg/dL
Sickle Cell Screen-PRN
☐ ☐
☐ System Review Within Normal Limits
☐
Abnormal Findings – List Other Pertinent Medical Concerns Below (e.g., concussion, mental health, one functioning organ)
☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech
☐ Dental ☐ Cardiovascular ☐ Back/Spine/Neck ☐ Skin ☐ Social Emotional
☐
Mental Health
☐
Lungs
☐
Genitourinary
☐
Neurological
☐
Musculoskeletal
☐
Assessment/Abnormalities Noted/Recommendations:
Diagnoses/Problems (list) ICD-10 Code*
☐
Additional Information Attached
*Required o
nly for students with an IEP receiving Medicaid
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Name:
Affirmed Name
(if applicable)
:
DOB:
SCREENINGS
Vision & Hearing Screenings Required for PreK or K, 1, 3, 5, 7, & 11
Vision
With Correction ☐Yes ☐ No
Right
Left
Referral
Not Done
Distance Acuity
20/
20/
☐
Yes
☐
Near Vision Acuity
20/
20/
☐
Color Perception Screening ☐
Pass ☐
Fail ☐
Notes
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.
Not Done
Pure Tone Screening
Right ☐ Pass ☐ Fail Left ☐ Pass ☐ Fail Referral ☐ Yes ☐
Notes
Scoliosis Screening: Boys grade 9, Girls grades 5 & 7
Negative
Positive
Referral
Not Done
☐ ☐
☐
Yes
☐
FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS*/PLAYGROUND/WORK
☐ *Family cardiac history reviewed – required for Dominic Murray Sudden Cardiac Arrest Prevention Act
☐
Student may participate in all activities without restrictions.
If Restrictions Apply – Complete the information below
☐
Student is restricted from participation in:
☐
Contact Sports: Basketball, Competitive Cheerleading, Diving, Downhill Skiing, Field Hockey, Football, Gymnastics, Ice
Hockey, Lacrosse, Soccer, and Wrestling.
☐ Limited Contact Sports: Baseball, Fencing, Softball, and Volleyball.
☐ Non-Contact Sports: Archery, Badminton, Bowling, Cross-Country, Golf, Riflery, Swimming, Tennis, and Track & Field.
☐ Other Restrictions:
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: ☐ I ☐ II ☐ III ☐ IV ☐ V
☐
Other Accommodations*: (e.g., brace, orthotics, insulin pump, prosthetic, sports goggles, etc.) Use additional space
below to explain.
*Check with the athletic governing body if prior approval/form completion is required for use of the device at athletic competitions.
MEDICATIONS
☐
Order Form for medication(s) needed at school attached
COMMUNICABLE DISEASE
IMMUNIZATIONS
☐ Confirmed free of communicable disease during exam ☐ Record Attached ☐ Reported in NYSIIS
HEALTHCARE PROVIDER
Healthcare Provider Signature:
Provider Name: (please print)
Provider Address:
Phone:
Fax:
Please Return This Form to Your Child’s School Health Office When Completed.