Póliza Sobre el Uso de Drogas - West New York School

WEST NEW YORK PUBLIC SCHOOLS
Physical Examination for Student Health Appraisal [PART 1 of 2]
TO BE COMPLETED BY THE PHYSICIAN AND RETURNED TO THE SCHOOL NURSE WITHIN 15 DAYS
THE EXAMINING PHYSICIAN IS RESPONSIBLE FOR INFORMING THE SCHOOL OF ANY HEALTH
PROBLEMS, WHICH MAY HINDER THIS CHILD FROM FULL PARTICIPATION IN THE SCHOOL HEALTH AND
PHYSICAL EDUCATION PROGRAM.
Note: check mark indicates normal findings
Name:________________________________________Birth Date:________________________
Address:_________________________________________________________School:________
History of Immunizations:
DTaP/DTP/ 1.____________ Pneumococcal 1.___________ I.P.V. 1.___________
Td 2.____________ Conjugate 2.___________ 2.___________
3.____________ (PCV 13) 3.___________ 3.___________
4.____________ 4.___________ 4.___________
5.____________
5.___________
HEP A. 1.___________
M.M.R. 1.____________ 2.___________ Varicella: 1.___________
2.____________
2.___________
MANTOUX:
Date given: __________ Date Read: ________ H.I.B. 1.___________
Reaction: __________ 2.___________
X-ray: __________ 3.___________
4.___________
Treatment: INH STARTED: ______________
DOSE: ______________
DURATION: ______________ HEP. B 1.___________
COMPLETED: ______________
2.___________
3.___________
4.___________
FLU Vaccine must be administered between Sept. 1 st & Dec .31 st Date given: _____________
11 YR. Olds must have: Tdap: ________________ MENINGOCOCCAL: _________________
CONJUGATE (MCV 4)
Recommended for ages 9 & older: H.P.V: 1. ____________ 2. ____________ 3. __________
OTHER: ____________________________________________________________________
Laboratory Findings:
Hgb/Hct.: _________ Urinalysis: _________ Lead: _________ Other: _________
Does this child take any medication? Yes___ No___
Please indicate name of the medication and if it is to be given in school.
_________________________________________________________________________________________________
Is there a history of any serious injuries, accidents or operations? Yes___ No___
Is there any impairment, disease or illness, past or present, of which
the school should be informed and to which special consideration should
be given? Yes___ No___
Is the child under the care of a specialist? Yes___ No___
If yes, who and why? __________________________________________
General condition: __________________________________________________________
____________________ ____________________ ___________ _______________________________
Print Doctor’s Name Signature Date Health Care Provider’s Stamp
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