Get Niagara Falls School District Physical Form

School District of the City of Niagara Falls Department of Health Services PHYSICAL EXAMINATION NameD O BSchool I hereby grant permission for the medical staff of the Niagara Falls City School District to obtain medical information from my child s health care provider pertaining to the information indicated in this physical. Parent/guardian Signature Immunization record attached No Immunization given today IMMUNIZATIONS/HEALTH HISTORY Sickle Cell Screen PPD Elevated Lead Dental Referral Positive Yes Negative No Not done Date Significant Medical/Surgical History SEE ATTACHED Allergies Life Threatening Seasonal Food Insect Other Medication Date of exam Height Weight Vision R Body Mass Index. BMI Percentile 5 5 - 49 50 - 84 L B. P. Pulse 85 - 94 95 -98 99 and higher EXAM ENTIRELY NORMAL specify any abnormality use reverse of form if needed Scoliosis Menarche LMP PLEASE SPECIFY CURRENT DISEASES Testes Asthma Diabetes Type 1 Hyperlipidemia Tanner Stage I II III IV V Type 2 Hypertension MEDICATIONS Medication None Medication at home only Medication to be given at school Dosage/Time list additional medications on reverse of form If AM dose is missed at home I assess this student to be self- directed and may self-carry medication PHYSICAL EDUCATION/ SPORTS/ PLAYGROUND /WORK QUALIFICATION /CSE CONSIDERATION Interscholastic sports participants must be seen by the District Nurse Practitioners Free from contagions physically qualified for all physical education sports playground work and school activities OR only as checked below Limited contact baseball basketball softball volleyball diving Strenuous/non-contact cross country track field swimming tennis indoor track Non strenuous/non-contact bowling golf cheerleading Specify medical accommodations needed for school None Known or suspected disability Please monitor Restrictions Protective equipment required Athletic Cup Sport goggles/impact resistant eyewear Other Provider s Signature Phone stamp below Provider s Name/Address Fax NYSED requires an annual exam for new entrants students in grades Pre-K or K 2 4 7 10 sports working permits and triennially for the Committee on Special Education CSE. School District of the City of Niagara Falls Department of Health Services PHYSICAL EXAMINATION NameD O BSchool I hereby grant permission for the medical staff of the Niagara Falls City School District to obtain medical information from my child s health care provider pertaining to the information indicated in this physical* Parent/guardian Signature Immunization record attached No Immunization given today IMMUNIZATIONS/HEALTH HISTORY Sickle Cell Screen PPD Elevated Lead Dental Referral Positive Yes Negative No Not done Date Significant Medical/Surgical History SEE ATTACHED Allergies Life Threatening Seasonal Food Insect Other Medication Date of exam Height Weight Vision R Body Mass Index. BMI Percentile 5 5 - 49 50 - 84 L B. P. Pulse 85 - 94 95 -98 99 and higher EXAM ENTIRELY NORMAL specify any abnormality use reverse of form if needed Scoliosis Menarche LMP PLEASE SPECIFY CURRENT DISEASES Testes Asthma Diabetes Type 1 Hyperlipidemia Tanner Stage I II III IV V Type 2 Hypertension MEDICATIONS Medication None Medication at home only Medication to be given at school Dosage/Time list additional medications on reverse of form If AM dose is missed at home I assess this student to be self- directed and may self-carry medication PHYSICAL EDUCATION/ SPORTS/ PLAYGROUND /WORK QUALIFICATION /CSE CONSIDERATION Interscholastic sports participants must be seen by the District Nurse Practitioners Free from contagions physically qualified for all physical education sports playground work and school activities OR only as checked below Limited contact baseball basketball softball volleyball diving Strenuous/non-contact cross country track field swimming tennis indoor track Non strenuous/non-contact bowling golf cheerleading Specify medical accommodations needed for school None Known or suspected disability Please monitor Restrictions Protective equipment required Athletic Cup Sport goggles/impact resistant eyewear Other Provider s Signature Phone stamp below Provider s Name/Address Fax NYSED requires an annual exam for new entrants students in grades Pre-K or K 2 4 7 10 sports working permits and triennially for the Committee on Special Education CSE.