• HEALTH CERTIFICATE / APPRAISAL FORM

     

     

    Name:                                                                                                                         Date of Birth:                                                                                    

    School:                                                                              Gender:   q M   qF    Grade:                                                                                               

     

    IMMUNIZATIONS / HEALTH HISTORY

    r Immunization record attached                                                            Sickle Cell Screen: r Positive   rNegative  r Not done   Date:                      

    r No immunizations given today                                                            PPD:                         r Positive   rNegative  r Not done  Date:                       

    r Immunizations given since last Health Appraisal:                              Elevated Lead:        r Yes        r No         r Not done   Date:                        

                                                                                                                    Dental Referral        r Yes       r No         r Not done   Date:                        

                                                                                                                                                                                                                                                                                    

    Significant Medical/Surgical History:  r See attached                                                                                                                                                                                                                                                                                                                                                                                               

    Allergies:                                                  r LIFE THREATENING                                r Food:           r Insect:                       r Other:                                                                                                

                   r Seasonal                     r Medication:                                                                                                                                                         

     

    PHYSICAL EXAM

     

    Height:  _______________            Weight:  _______________             Blood Pressure:  _______________         Date of Exam:                                      

                                                                                                                                                                                                                                    Referral

    Body Mass Index:   ____ ____ . ____

       Vision - without glasses/contact lenses

     R

     L

     

    Weight Status Category  (BMI Percentile):

     Vision - with glasses/contact lenses

     R

     L

     

    q less than 5th               q 5th through 49th          q 50th through 84th 

     Vision - Near Point

     R

     L

     

    q 85th through 94th        q 95th through 98th         q 99th and higher

     Hearing  q Pass 20 db sc both ears or:    

     R

     L

     

     

    r  EXAM ENTIRELY NORMAL          Tanner:     I.        II.        III.        IV.       V.           Scoliosis:  r  Negative  r Positive:                                  

    Specify any abnormality (use reverse of form if needed):                                                                                                                                                                                                                                                                                                                                                                                                   

                                                                                                                                                                                                                                                   

    MEDICATIONS

    Medications (list all):                r None      r Additional medications listed on reverse of form

     

    Name:  ____________________________________________________   Dosage/Time:  _________________________________________________

     

    Name:  ____________________________________________________   Dosage/Time:  _________________________________________________

     

    If AM dose is missed at home:  ________________________________________________________________________________________________

     

    I assess this student to be self-directed   r Yes    r No                  Student may self carry and self administer medication  r Yes    r No

    Note: Nurse will also assess self-direction for the school setting.   Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given.

    PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

     

    r   Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:   

     

    ___  Limited contact:  cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.

    ___  Non-contact:  badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

    r   Specify medical accommodations needed for school:                                                                                            r  None

     

    r    Known or suspected disability:                                                                                                                                                   r  Please monitor

     

    r    Restrictions:                                                                                                                                                                                     r  Please monitor

     

    r    Protective equipment required:    r Athletic Cup      r Sport goggles/impact resistant eyewear      r Other:                                                                 

    OPTIONAL INFORMATION, if known

    Specify current diseases:                     r Asthma          Diabetes:   r Type 1                   r Type 2                r  Hyperlipidemia                    r  Hypertension

                                                                        r Other:                                                                                                                                                             

    Provider’s Signature:                                                                                                     Phone:                                                                   (Stamp below)

    Provider’s Name/Address:                                                                                            Fax:                                                  

    Parent Signature:                                                                                                          Date: