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NYS Health Examination Form

Required

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:required
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Sex Assigned at Birth:required
Gender Identityrequired
Must contain a date in MM/DD/YYYY format
HEALTH HISTORY
If yes to any diagnoses below, check all that apply and provide additional information.
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Asthma
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Must contain a date in MM/DD/YYYY format
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Diabetes Type:
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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.
kg/m2
Percentile (Weight Status Category):
Hyperlipidemia:
Hypertension:
PHYSICAL EXAMINATION/ASSESSMENT
Laboratory Testing
TB- PRN
Must contain a date in MM/DD/YYYY format
Sickle Cell Screen-PRN
Must contain a date in MM/DD/YYYY format
Lead Level Required for PreK & K
Must contain a date in MM/DD/YYYY format
System Review
Additional Info
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ICD-10 Code*
Namerequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
SCREENINGS
Vision & Hearing Screenings Required for PreK or K, 1, 3, 5, 7, & 11
With Correction
Referral
Distance Acuity
Near Vision Acuity
Color Perception Screening
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.
 
Pure Tone Screening
Right
Left
Referral
Pure Tone Screening
Scoliosis Screening: Boys grade 9, Girls grades 5 & 7
Referal
Scoliosis Screening

FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS*/PLAYGROUND/WORK

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:
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:
*Check with the athletic governing body if prior approval/form completion is required for use of the device at athletic competitions.
MEDICATIONS
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COMMUNICABLE DISEASE
IMMUNIZATIONS
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HEALTHCARE PROVIDER
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