Sample Certificate of Sports by ebl11923

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									                                                                                                                         Recommended / Sample Form
                NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and
                                               triennially for the Committee on Special Education (CSE).
                                              HEALTH CERTIFICATE / APPRAISAL FORM
Name:                                                                                                    Date of Birth:

School:                                                                  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
                th               th            th              th                 th
  less than 5                   5 through 49               50 through 84                 Vision - Near Point                           R                L
     th               th          th            th             th
  85 through 94                 95 through 98              99 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:


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
                           WILSON CENTRAL SCHOOL PRE-PARTICIPATION SPORTS PHYSICAL

Name___________________________________ Address_________________________________ Zip__________ Phone_____________

Date of Birth________________ Age__________ Grade_________ School Year____________ Student ID__________________

Parent’s Name________________________________________

In case of emergency, notify:   Name_______________________________________ Address_________________________________

Phone_________________ Hospital Preference___________________________ Family Doctor__________________________________
Date of last tetanus booster____________________________ Date of last examination by a doctor_______________________________
I UNDERSTAND THAT FAILURE TO ANSWER THE QUESTIONS BELOW ACCURATELY WILL DISQUALIFY ME FROM
ANY SPORTS PARTICIPATION ____________________________________________________________ (Signature)
                  The following questions are to be answered by either yes or no. Please check the appropriate space.
                                                     YES    NO                                                         YES NO
Have you been under a doctor’s care in the past                             Have you had or do you now have:
 12 months?                                          ( )    ( )              Back injury or frequent backaches?        ( ) ( )
Have you been in the hospital in the past
 12 months?                                          ( )    ( )              Knee injury (sprain) or recurrent pain? ( )   ( )
Have you ever had any type of surgery?               ( )    ( )              Ankle injury (sprain) or recurrent pain? ( )  ( )
Do you want to talk to a doctor about a health                               Other joint problems (e.g. swelling, pain
 Problem or an inury?                                ( )    ( )                  Decreased range of motion?            ( ) ( )
Has anyone in your immediate family ever had:                                Bone infection?                           ( ) ( )
 Diabetes (high sugar in blood)?                     ( )     ( )             Arthritis?                                ( ) ( )
 Allergies (hay fever or asthma)?                    ( )     ( )            Have you had or do you now have:
 Migraine Headaches?                                 ( )     ( )             Diabetes (high sugar in blood or urine)? ( )  ( )
 Heart Trouble?                                      ( )    ( )              Tendency to bleed or bruise easily?       ( ) ( )
 High Blood Pressure?                                ( )     ( )             Anemia (“tired” blood)?                   ( ) ( )
Has anyone in your family, under age 50, died                                Nosebleeds frequent or severe? (Circle)   ( ) ( )
suddenly?                                            ( )    ( )
Have you had or do you now have:                                             Asthma (wheezing)?                        ( ) ( )
 Brain concussion (head injury)?                     ( )    ( )                Medication:______________________
 Tendency to lose consciousness (faint)?             ( )    ( )                 Inhaler:_________________________ ( )      ( )
 Skull fractures?                                    ( )     ( )             Hay Fever?                                ( ) ( )
 Convulsions/epilepsy/seizures?                      ( )     ( )             Hives or rash?                            ( ) ( )
 Neck injury?                                        ( )    ( )              Bee-sting reactions (allergy)?            ( ) ( )
 Very bad (impaired) vision in one eye               ( )    ( )              Reaction to medicine                      ( ) ( )
 Temporary loss of vision?                           ( )    ( )                  Name:_________________________
 To wear glasses or contact lenses? (Circle)         ( )     ( )             Other allergies? List ________________
Have you had or do you now have?                                            ___________________________________
 Hearing loss?                                       ( )     ( )            Do you:
 Perforated eardrum?                                 ( )     ( )             Smoke?
 Discharge from ear(s)                               ( )     ( )             Take any medicine regularly? If so,       ( ) ( )
          (recurrent infections)                     ( )    ( )               Please list_________________________
 Sinus infections?                                   ( )     ( )            Have you had or do you now have?
 Orthodontia (teeth straightened)                    ( )     ( )             Heart trouble or murmur?                  ( ) ( )
 Hernia?                                             ( )     ( )             High blood pressure?                      ( ) ( )
 Kidney problems?                                    ( )     ( )             Persistent cough?                         ( ) ( )
  Heat exhaustion?                                   ( )     ( )             Chest pain with exercise?                 ( ) ( )
  Mononucleosis?                                     ( )     ( )             Dizziness or faintness with exercise?     ( ) ( )
Loss of function or absence of testicles (boys)?     ( )     ( )             Recurrent rash?                           ( ) ( )
Mentrual problems (girls)?                           ( )     ( )             Fungus infection?                         ( ) ( )
  Age of onset of menstruation_______________                                Athlete’s foot?                           ( ) ( )
  Month/Year of first menses________________                                 Recurrent boild (skin infection)?         ( ) ( )
Have you had or do you now have:                                             Do you wish to discuss an emotional
                                                                                 problem with the doctor?              ( ) ( )
 Bone fracture?                                      ( )    ( )              Have you ever been told to give up
                                                                             sports because of a health problem?       ( ) ( )
 Joint dislocation?                                  ( )     ( )
 Nose Fracture?                                      ( )    ( )
 List date & injury_________________________
__________________________________________

								
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