Name: Sex: Birthday:

Parent/Guardian Name /
Address
/
Phone
/
Cell
/
Bus. Phone
School Name & Location
/
Date Entered Date Left
/
Emergency Contact
/
Phone
Physician Name
/
Phone

IMMUNIZATIONS

DTaP / Tdap / Sickle Cell
Polio (OPV/IPV) / MenACWY / PPD
MMR / HPV / ­ Lead
Hep B
Varivax disease
Hib / PCV

HEALTH HISTORY

Skin Condition / Allergies  Epi-Pen / Seizure Disorder / Single Organ
Head Injury / Asthma / Kidney Defect / Serious Illness
Eye Defect / Diabetes  Type1  Type 2 / Blood Immune Condition / Operations/Hospitalization
Hearing Impairment / Heart Condition/↑BP / Muscular/Skeletal / Injuries
Lung Condition / Hyperlipidemia / Neurological Disorder / Medications

SCREENING PROCEDURES

Grade:
Height:
Weight:
Date:
With Correction R
Glasses/Contacts L / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/
20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/
No Correction R
L / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/
20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/ / 20/
Referral Date
Near Vision: / Color Perception:
Date:
R
L / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc
sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc / sc
Referral Date
SCOLIOSIS Date:
Results:
Referral /Date:
Dental Certificate:

HEALTH APPRAISALS

Age/Grade: / / / / / / / / / / / / / / / / / / / / / / / / / / / /
Blood Pressure
Tanner Stage
BMI Percentile
Weight Status Category
Skin
HEENT/Teeth
Lymph/Thyroid
Cardiovascular
Lungs
Abdomen
Genito-urinary
Orthopedic

Scoliosis - Thoracic

Lumbar

Sacral
Nervous System
Behavior
Speech
Sports Qual. Code
PE Date:
MD/DO/NP/PA:

Classification per Contact: 1. Contact Sports: Basketball, Competitive Cheer, Field Hockey, Football, Gymnastics, Ice Hockey, Lacrosse, Soccer, Wrestling

2. Limited Contact: Baseball, Fencing, Softball, Volleyball NYSCSH 10/2017

3. Non-Contact: Archery, Badminton, Bowling, Cross-Country, Diving, Golf, Rifle, Skiing, Swim, Tennis, Track & Field

*WSC Percentile: p less than 5th p 5th through 49th p 50th through 84th p 85th through 94th p 95th through 98th p 99th and higher