Health Exam Form

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: Exam Date:
HEALTH HISTORY
If yes to any diagnoses below, check all that apply and provide additional information.
Type:
☐ Allergies
☐ Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached
☐ Intermittent ☐ Persistent ☐ Other:
☐ Asthma
☐ Medication/Treatment Order Attached ☐ Asthma Care Plan Attached
Type: Date of last seizure:
☐ Seizures
☐ Medication/Treatment Order Attached ☐ Seizure Care Plan Attached
Type: ☐ 1 ☐2
☐ Diabetes
☐ 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):  < 5th  5th- 49th  50th- 84th  85th- 94th  95th- 98th  99th and >
Hyperlipidemia: ☐ Yes ☐ Not Done Hypertension: ☐ Yes ☐ Not Done
PHYSICAL EXAMINATION/ASSESSMENT
Height: Weight: BP: Pulse: Respirations:
Lead Level
LaboratoryTesting Positive Negative Date 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 only for students with an IEP receiving Medicaid
5/2023 Page 1 of 2
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;
Not Done
for grades 7 & 11 also test at 6000 & 8000 Hz.
Pure Tone Screening Right ☐ Pass ☐ Fail Left ☐ Pass ☐ Fail Referral ☐ Yes ☐
Notes
Negative Positive Referral Not Done

Scoliosis Screening: Boys grade 9, Girls grades 5 & 7
☐ ☐ ☐ 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.
5/2023 Page 2 of 2

Health Exam Form

Uploaded by

Copyright:

Available Formats

Health Exam Form

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Health Exam Form

Uploaded by

Copyright:

Available Formats

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM

TO BE COMPLETED BY PRIVATE HEALTHCARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Negative Positive Referral Not Done

You might also like