SHENENDEHOWA
CENTRAL SCHOOLS
School Health Examination, Gr. K-5
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Name DOB Grade School A physical is required by EDUCATION LAW for the following students: kindergartners, new students to Shenendehowa, and students entering 2nd and 4th grades. The physical can be done within 12 months prior to the start of school, no earlier than September 1st. Completed forms should be returned to the health office in the student’s school.
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| Height: ________ Weight: _______ | SPECIFIC DATES OF IMMUNIZATION |
| Eyes: R _______ L_______ | DPT __________________________________________ |
| Ears (Otoscopic) ( R ) _____ ( L ) ______ | DTaP ___________ DT ___________________ |
| Lymph Nodes_____________________________ | Td ______________ TB Test _______________ |
| Thyroid _________________________________ | Oral Polio ______________________________________ |
| Breast __________________________________ | Varicella Vaccine _________________________________ |
| Nose ___________________________________ | HIB ___________________________________________ |
| Tonsils _________________________________ | MMR #1_________________ #2 ___________________ |
| Teeth __________________________________ | Measles #1________________ #2 ___________________ |
| Heart ________________ BP ______/_______ | Mumps _______________ Rubella _________________ |
| Lungs
__________________________________ Hernia __________________________________ Genito-Urinary ____________________________ |
Hep B (3-dose series)______________________________ |
| Orthopedic Structural
______________________ Posture ________________________ Feet ___________________________ |
HEALTH HISTORY |
| Physician, please note: State legislation mandates scoliosis screening for each child in grades 5 through 9. | Previous Illnesses
_________________________________ Allergies ________________________________________ Surgery _________________________________________ |
| Please mark the proper box: Screening negative ¨ Screening positive ¨ Follow-up________________________________ |
Chronic Conditions
________________________________ Physical Limitations ________________________________ Any restrictions to full participation in physical education? _______________________________________________ |
| Skin
____________________________________ Nervous System ___________________________ Nutrition _________________________________ Speech __________________________________ Other ___________________________________ |
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Physicians Signature___________________________ Physicians Stamp _____________________________ Date of Exam ______________________ |
HA1
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Dear Parent/Guardian: In our efforts to be of service to both students and parents at Shenendehowa, the School Nurse Department is taking this opportunity to remind you of the following: Education Law (Section 903) requires that a health certificate be furnished by each pupil upon his/her entrance to the kindergarten, second, fourth, seventh, and tenth grades. It must be done within 12 months of the start of school, i.e. no earlier than September 1, 2005. We are reminding you of this requirement so you may take the appropriate steps to schedule a physical examination for your son/daughter. We believe that your personal family physician can offer a more complete examination through his/her knowledge of your family than our school physician can accomplish during the time period available in school. A copy of the School Health Examination form reproduced on the reverse side of this page is for your use and that of your family physician. When your child’s physical has been done, the completed form should be returned/mailed to the appropriate school health office. Your cooperation in this matter will be sincerely appreciated.
Sincerely,
Michael Smith
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