Scotia-Glenville Central School District

Scotia, New York 12302

Name __________________________________ Date of birth __________ Grade/Class __________

Physician’s name/address/phone _______________________________________________________________

The New York State Education Law requires that school children have a health examination upon entrance to school (all new entrants and Kindergarteners), and routinely in grades 1, 3, 7 and 10. This physical may be performed no earlier than 90 days prior to the first day of attendance at school. For participation in interscholastic sports, the physical will be valid for one calendar year from the date of the exam. An examination by your family physician is recommended since that exam is more thorough than the screening examination received at school. Children in Kindergarten, grades 1, 3, 7 and 10, and new entrants who have not presented a record of examination upon entrance to school will be examined by the school physician during the school year.

*************************HEALTH/SPORTS PHYSICAL EXAMINATION*************************

Please use "N" for normal or negative, "X" for defect found or under treatment.

Eyes____________________________ Skin (Non-Communicable)______________________

Ears(Otoscopic)___________________ Epilepsy_________________________________

Lymph Nodes_____________________ Nervous System___________________________

Thyroid__________________________ Speech_________________________________

Nose____________________________ Nutrition_________________________________

Tonsils___________________________ Height______________ Weight______________

Teeth____________________________Vision___________________________________

Heart____________________________ Hearing_________________________________

Blood Pressure____________________ Orthopedic:

Lungs_______________________________Feet_________________________________

Hernia______________________________ Posture______________________________

Genito-Urinary_________________________ Structural____________________________

Urine_________________Scoliosis: positive______ negative_____follow-up____________

Changes advised in school routine: ***Physician, please note: NY State Law requires scoliosis screening for all children between the

ages of 8 and 16 years.

*************************************IMMUNIZATION HISTORY*************************************

POLIO________* ________* ________* DPT________* ________* ________* ________

MMR________* ________* MEASLES__________* __________*

OR MUMPS__________*

RUBELLA__________*

HIB________ ________ ________ ________ TUBERCULIN TEST_______ result________

HEPATITIS B________* ________* ________* *required by New York State Law

THREE doses of HEPATITIS B vaccine are required for children born on or after 1/1/93.

**********************************************************************************************************

This certifies that the above named student is physically qualified to participate in the following categories of competition during the school year (check all that apply):

__________ ALL SPORTS - includes Contact or Collision Sports - Football, Baseball. Basketball, Soccer, Hockey, Wrestling, Lacrosse, Softball

__________ ENDURANCE ACTIVITIES - Gymnastics,Track, Cross-Country, Tennis, Skiing, Volleyball, Handball

__________ OTHERS - Bowling, Golf, Archery, Field Events, Cheerleading

MATURITY LEVEL - GRADE 7 & 8 ONLY - COMPLETE ATTACHED SHEET.

DATE of EXAM____________ PHYSICIAN SIGNATURE________________________________

Co-Signature of School Physician is required for any exam performed by any health personnel other than the School Physician(s).

Date of Review_________________ School Physician Signature_____________________________________

Revised Spring 1997

USE OF PERSONAL DOCTOR

FOR SPORT PHYSICAL

PROCEDURE

1. Bring your completed doctor’s physical examination form to the School Nurse.
2. The School Nurse will then have the school physicians co-sign the form for eligibility to participate in
3. a school sport.
4. Once the physical form is co-signed and an interval health history form is given to the School Nurse,