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St. Helen's School 2008-2009 Medical Inspection Form


           
Online forms are available for your use in registration.
Please complete, print, sign (if applicable), and submit to the school office.

If you have any questions, please contact the office at 382-8225.

NOTE: This form is to be completed by your physician.

Dear Parent:
New York State Education Law requires that all new entrants and children in Grades Kindergarten, 2, 4, 7, and 10 must be examined by their own physician or the school physician. The physical exam shall not be more than twelve months prior to the commencement of the school year in which the examination is required. This report shall be returned to school not later than 30 days after entrance to the school or grade.
It is strongly recommended all kindergarten entrants be examined by their own physician. Click here to view the relevant state law.
           

Name of Pupil:

  _________________________  

Sex:

  ___________  

Birth Date:

  _________

School:

  _________________________  

Grade:

  ___________        

Height:

  _________________________  

Weight (lbs):

  ___________        

Eyes:

  RL  

With Glasses:

  RL    

Ears:
Hearing Loss:

  _________________________  

Other Defect:

  ________________________________________

Nutrition:

  _________________________  

Teeth:
(Temporary)

  ___________        

Gums:

  _________________________  

Teeth:
(Permanent)

  ___________        

Tonsils:

  _________________________  

Nose:

  ___________        

Glands:

  _________________________  

Thyroid:

  ___________  

Other:

  _________

Asthma:

  _________________________  

Allergies:
(Specify)

  ________________________________________

Heart:

  _________________________  

Blood Pressure:

  ___________  

Lungs:

  _________

Chest X-Ray:

  _________________________                
                     

Orthopedic:
Structural

  _________________________  

Scoliosis:

  ___________  

Feet:

  _________

Skin:

  _________________________  

Hernia:

  ___________  

Genito-Urinary:

  _________

Speech:

  _________________________  

Epilepsy:

  ___________  

Nervous System:

  _________

BMI:

  ________________                 
Childhood Immunizations
  

Dates

Polio
DPT            
Hepatitis B            
Measles, Mumps, Rubella            
HIB            
Varicella            
Other            

Restrictions or Modifications for Physical Education: ____________________________________________________________________

______________________________________________________________________________________________________________
 
If under any special medical treatment, or if there are any recommendations to the school nurse for follow-up, please state
(if more space is needed, please use additional paper and attach to this form.):

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________
 
Physician's Signature: _________________________________________________________________

Physician's Name: (Please Print) _________________________________________________________

Date of Physical: ________________________