EDGEMONT UNION FREE SCHOOL DISTRICT

Note:NYSEDrequiresanannualphysicalexamforn"*"nt.a,'ts'nu'tuo"interscholastic sports and working papers

DOB:

Grade:Gender: trM trF

Exam Date:

PPD: flPositive

Elevated Lead: [YesDental Referral: Eyes

ENegative ENot Done Date:

ENo nNot Done Date:

EAsthma (Elntermittent or flpersiitent )

Quick relief inhaler: Eyes ENoAsthma Action plan: Eyes EINo

[3Type 1 Diabetes EIType 2 Diabetes[lHyperlipidemia flHypertensionflOther:

ElAllergies - See page 2 for details.

Medical/Surgical lnformation :

PHYSICAT EXAMINATION

Pulse: nespiratlons:

Degree of deviation: _Angle of trunk rotation via scoliometer: Distance acuity with lenses

ight Status Category (BMt percentile):

<sth E 85th- 94nh

5,h_ 4g,h n gs,h_ ggrh

Ef 5oth-84th E ggth &

Vision - near vision

E Zo aO sweep screen both ears ordl!rl!T,",ilil"'e" (o

"SYSTEM REVIEW AND EXAM ErurIneIv I'Ionruar.Specify any abnormalities:

RECOMMENDATIONS OR RE5TRICTIONS FOR PARTICIPA

3I:::1oT^.o:.1*ion''ndhysed,athletics,playground,work,school)EI Expected Body contact (full or limited): football, wrestling, basketball, ice/field/floor hockey, baseball, softball,fl strenuous: cross-country, gymnastics, track & field, swim, diving, crew, ski, cheering, tennis, badminton, fencing,E Non-contact/Non-strenuous: bowling, golfing, table tennis, archery, riflery, shuffleboard, walkingfl Protective Equipment: flAthletic cup Esport/safety goggles flother:E Medical/prosthetic device:

Recom mendations/restrictions:

Page L of 2

Name: DOB:

MEDICATIONS

To be completed by Health Care Provider

Diagnosis ICD Code Medication Name Dose Route TimeSelf

Directed*Self Admin/Self Carry**

n trtr ntr trn tru tr

>err urrecEeq: ! assess rnrs SIuoenI 15 setT-otrefieo regarotng tnetr meotcauon. tney tne purpose, name, amount, dose, timingEncfefficf taking or not taking the medication, can recognize the medication and refuse to take it inappropriately, and can ingest, inhale, apply or calculaternd administer the correct dose of the medication independently.-5elfAdmin/5elf-ca'ry:lhavedeterminedthisstUdentisconsistentandresponsibleintakingtheirownmedicatio@give them permission to self-carry and self-administer this medication. They will be considered independent in medication delivery and needntervention only during emergencies.

To be completed by Parent/Guardian if medication is prescribedf]lgivepermissionfortheabovemedicationtobeadministeredtomychitdawill furnish the medication in the original pharmacy container, properly labeled with directions and dosage, or originalover-the-counter medication container/package with my child's name on it.Parent/Guardian Siglature: Date: phone: ( )

tr Parent permission & provider consent is required for students to self-administer & self-carrv medication- Srrrrtontcwith this designation are considered independent in taking their medication at school and require no supervision by thenurse. Parents assume responsibility for ensuring that their child is carrying and taking their medication as ordered.Schools may revoke the self-carry/self-administer privilege if the student proves to be irresponsible or incapable. Torequest this option please sign below.

Pa rent/Guardian Signature: Phone: ( )Date:

AttERGIES

tl None tr Non Life-Threatening tr life-Threateningfype: flFood Elnsect ILatex EMedication [fSeasonal/Environmental EOther:Specify allergen(s):Specify previous symptoms: flHistory of anaphylaxis; last occurrence:Emergency Care Plan for anaphylaxis: E Yes tr Norreatmen! prescribed: ENone EAntihistimine EEpinephrine Autoinjector

IMMUNIZATIONS

E lmmunization record attached

E lmmunizations reported on NYSIIS

fl No immunizations received today

fl lmmunizations received today:

I Will return on: to receive:

Provider / Parental AuthorizationAll information contained herein is valid through the last day of the month flor L2 months from the date Uelor,y.

Medical Provider Signature: Date:Provider Name: (please print) phone #:Provider Address: Fax #:Parent/Guardian Signature: Date:

Return to:School Nurse:

Phone #: ( ) Fax: ( )

School:

Date:

Page 2 of 2