Name of Student: _________________________  DOB ___/____/___ School: _____________ Grade: ____ Sport:___________

Height: _______      Weight: ______       %Body Fat (opt):   _____      Pulse:  ______     BP ____/____(____/____)

Vision:    R 20/___       L 20/ ___                 Corrected:    Y     N                    Auditory Screening:     R____      L____

Immunizations:  DPT #1 ________  DPT #2________ DPT #3 ________  Last DT _______ OPV #1________  OPV #2________  OPV #3_______

Hep B #1____________  Hep B #2____________  HepB #3____________  Varicella Vaccine_______________   Varicella Disease ________________

MMR #1____________  MMR #2____________  Pneumococcal____________ Meningococcal ___________

Normal

Abnormal with Comment

Initials

Exam

MEDICAL EXAM

Notes:  Please list medications, allergies, past medical history, past surgical history (if not listed on health history)

Appearance

Current Medications:

Eyes/Ear/Nose/Throat

Thyroid

Allergies:

Lymph Nodes

Heart

Surgical History:

Lungs

Pulses

Physical Limitations:

Abdomen

Hernia

Genitalia (males only)

Skin

MUSCULOSKELETAL

Are there any limitations to

Neck

participation in Physical Education?

Back/Scoliosis

If so, please explain:

Shoulder/Arm

Elbow/Forearm

Wrist/Hand

Hip/Thigh

Knee

Leg/Ankle

Foot

MEDICAL CLEARANCE:   Check appropriate areas of participation in a competitive sport.  An unmarked box indicates disqualification for that group of activities

Reasons for disqualification:
This certificate is void if the pupil is absent from school five (5) or more consecutive days because of illness or significant injury.  A new certificate must be issued before he/she is allowed to participate.
PHYSICIAN INFORMATION:  Name of Physician (Print/Type/Stamp)_____________________________________________
Address: ___________________________________________________________Phone:_________________________________
Signature of Physician _________________________________________________Date of Exam:____________________

                                                                                                        Physicians Stamp:

HPE5 (revised 12/05)

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
Director of Student Services