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Annual Health Form

Required

Student Health Examina (To be completed by private health care provider or school medical director)
Note NYSED requires a physical exam for new entrants and students and Grades pre-K or K, 1, 3, 5, 7, 9, and 11, all interscholastic sports and working papers.
Name:required
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender:required
Must contain a date in MM/DD/YYYY format
Immunizationsrequired
Health History
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Asthma
Diabetes:

Seizures:

Allergies
Type:
Treatment prescribed:
Epinephrine Autoinjectorrequired
Significant Medical/Surgical Information: Positive Diagnostic Test:
Sickle Cell Screen
Must contain a date in MM/DD/YYYY format
PPD
Must contain a date in MM/DD/YYYY format
Elevated Lead
Must contain a date in MM/DD/YYYY format
Physical Examination
Scoliosis
Weight Status Category (BMI Percentile)
Vision
Distance acuity
Referral
Distance acuity with lenses
Referral
Vision - near vision
Referral
Vision color perception
Right
Left
Referral
Check developmental stage (only for Athletic Placement Process for 7th and 8th graders):
Tanner:
System Review and Exam Entirely Normal
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Recommendations for participation in Physical Education/Sports/Playground/Work
Restrictions/Adaptions
Other Specific Restrictions:
Medical History (optional)

Priovider Request for Medication Required During School/ Sponsored Events - Valid 1 Year
 

Independent Carry and Use Option: NYS law requires both provider attestation that the student has demonstrated they can effectively self-administer inhaled respiratory rescue medication, epinephrine autoinjector, insulin, glucagon and diabetes supplies, or other medications requiring rapid administration along with parent/guardian permission to allow this option in schools.

Required Parent/Guardian Permission for Medication Use at School

Parent/Guardian Permission: I request the school nurse give the medications listed on this plan; or after the nurse determines my child can take their own medications, trained staff may assist my child to take their own medications. I will provide the medication in the original pharmacy or over the counter container. This plan will be shared with staff caring for my child.

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Health Care Provider
 
All information contained herein is valid through the last day of the month for 12 months from the date below.
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Must contain a date in MM/DD/YYYY format
Must contain a date in MM/DD/YYYY format

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