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 2, 4, 7 and 10.  A physical exam is acceptable if it is performed within one year prior to the start of the school school year in which the physical is required.  For participation in interscholastic sports, the physical will be valid for one calendar year from the start of the exam.

HEALTH/SPORTS PHYSICAL EXAMINATION - SECONDARY LEVEL

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:                                     

                                                                                           

 

Tanner Rating  1   2   3   4   5  (Circle)

 

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

 

IMMUNIZATION HISTORY (Please complete below or attach copy of current immunizations)

 

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

                                           

MMR________* ________*                                            MEASLES__________* __________*                                            

                                                          OR                           MUMPS__________*                 

                                                                                           RUBELLA__________*                        

HIB________   ________   ________   ________                                                                TUBERCULIN TEST_______ result________

 

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

 

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_____________________________________

 

 

 

USE OF PERSONAL DOCTOR

FOR SPORT PHYSICAL

PROCEDURE

 

 

  1. Bring your completed doctor’s physical examination form to the School Nurse.

 

  1. The School Nurse will then have the school physicians co-sign the form for eligibility to participate in

      a school sport.

 

  1. Once the physical form is co-signed and an interval health history form is given to the School Nurse,

      the student will receive clearance to participate from the School Nurse.

 

 

SCHOOL NURSES

 

Middle School – Barbara Zabala, RN, Bonnie Lange, RN

10 Prestige Parkway

Scotia, New York  12302

(518)382-1266

fax # 386-4303

 

Senior High School – Susan Piehler, RN, Bonnie Lange, RN

1 Tartan Way

Scotia, New York  12302

(518)382-1250

fax # (518)386-4379

 

 

 

 

SCHOOL PHYSICIANS

 

Drs. Halbig, Buff, & Pezzulo

Scotia-Glenville Family Medicine, P.C.

112 Charlton Road

Ballston Lake, New York  12019

(518)399-7723

fax #(518)399-6428