HEALTH CERTIFICATE / APPRAISAL FORM

Name:   		Date of Birth:  	

	School:	Byron-Bergen Central School District	Gender:    M   F	Grade:		
				
IMMUNIZATIONS / HEALTH HISTORY	
 Immunization record attached	Sickle Cell Screen:   Positive    Negative   Not done   Date:  	
 No immunizations given today	PPD:	 Positive    Negative   Not done  Date:  	
 Immunizations given since last Health Appraisal:	Elevated Lead:	 Yes	 No	 Not done   Date:  	 Dental Referral	 Yes	 No	  Not done   Date:  	

Significant Medical/Surgical History:   See attached  	

	Allergies:     LIFE THREATENING	 Food:  		 Insect:  		 Other:  		
	 Seasonal	 Medication:  			
		PHYSICAL EXAM		

Height:   	

Weight:   	

Blood Pressure:   	

Date of Exam:  	
Referral

Body Mass Index:    	 	 .  		Vision - without glasses/contact lenses	
R	
L		
Weight Status Category  (BMI Percentile):	Vision - with glasses/contact lenses	R	L		
 less than 5th	 5th through 49th	 50th through 84th	Vision - Near Point	R	L		
 85th through 94th	 95th through 98th	 99th and higher	Hearing  Pass 20 db sc both ears or:	R	L		

  EXAM ENTIRELY NORMAL	Tanner:	I.	II.	III.	IV.	V.	Scoliosis:    Negative   Positive:  	

Specify any abnormality (use reverse of form if needed):  	

MEDICATIONS
Medications (list all):	 None	 Additional medications listed on reverse of form

Name:   	

Dosage/Time:   	

Name:   	

Dosage/Time:   	

If AM dose is missed at home:   		 I assess this student to be self-directed    Yes     No	Student may self carry and self administer medication   Yes     No
Note: Nurse will also assess self-direction for the school setting.   Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given.
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

   Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:
 	 Limited contact:  cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.
 	 Non-contact:  badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.
  Specify medical accommodations needed for school:  	   None

   Known or suspected disability:  	   Please monitor

   Restrictions:   	   Please monitor

    Protective equipment required:     Athletic Cup	 Sport goggles/impact resistant eyewear	 Other:   	
OPTIONAL INFORMATION, if known
Specify current diseases:	 Asthma	Diabetes:   Type 1   Type 2	 Hyperlipidemia	  Hypertension
 Other:  	

Provider’s Signature:  	Phone:  		(Stamp below)

Provider’s Name/Address:   	 Fax:   	

Parent Signature:  	 Date:  	

This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school medical director.	Rev. 2/08

INTERVAL HEALTH HISTORY FOR SPORTS PARTICIPATION

SCHOOL NAME:  BYRON-BERGEN CENTRAL SCHOOL DISTRICT

Prior to the start of tryout sessions or practice at the beginning of each season, a health history review for each athlete m ust be conducted unless the student received a full medical examination within 30 days of the start of the season.

PART A: TO BE COMPLETED BY THE SCHOOL HEALTH OFFICE
Student: 	

Age: 	

Grade (check):   7	 8	 9	 10	 11	 12	Date of Birth:   	/ 	/ 	

Sport: 	 High
Date of last health appraisal:  	_/_ 	/ 	

Level (check):  Varsity	 JV	 Freshman	 Jr.

Limitations:  Yes	No

PART B: TO BE COMPLETED BY THE PARENT OR GUARDIAN

NOTE: “Yes” to any of these questions does not mean automatic disqualification from the athletic activity indicated in PART A above.  However, it will require a review and approval by the school physician before the student can report to practice or tryouts.  The answers to the questions on this form will be held in the school health office, and will be kept confidential.

HISTORY SINCE LAST HEALTH APPRAISAL:

If the answer to any of the following questions is “YES”, in PART C below, please describe the condition or situation that prompted your answer.

1.	Any injuries requiring medical attention?	 Yes	 No	
2.	Any illness lasting more than five (5) days?	 Yes	 No	
3.	Taking medicine or under physician’s care at this time?	 Yes	 No	
4.	Any feeling of faintness, dizziness or fatigue after exercise or exertion?	 Yes	 No	
5.	Change in wearing glasses or contact lenses?	 Yes	 No	
6.	Any surgical operations or fractures?	 Yes	 No	
7.	Any treatment in a hospital or emergency room?	 Yes	 No	
8.	Developed any allergies?	 Yes	 No	
9.	Any chronic disease?	 Yes	 No	

PART C: TO BE COMPLETED BY PARENT OR GUARDIAN

Describe the condition or situation that caused any questions in PART B to be answered “YES”.

PART D: PARENTAL PERMISSION

I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate on the athletic team named in PART A of this form.  The answers are correct as of this date and he/she has my permission to participate.

SIGNED:   	

DATE:  	_/ 	_/ 	

PART E:  TO BE COMPLETED BY THE SCHOOL HEALTH OFFICE

Sports Participation:     Approved	 Referred to School Physician

Signed:   	 School Health Office

Date: 	/_ 	_/_ 	

If referred to the School Physician:	  Requalified	 Disqualified

Signed:   	 School Physician

Date: 	/_ 	_/_ 	

PLEASE RETURN TO THE SCHOOL HEALTH OFFICE