Port Jefferson School District Elementary Health History

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1 Elementary Health History Name: M F Grade: DOB: Address: Phone Birthplace Previous School: Address: Father Address if different from child: Language Spoken at Home: Family Physician: Emergency Contact: Mother Address if different from child: Name Telephone # Address Name: Relationship:_ Phone: Name: Relationship:_ Phone: Is there a History of: Asthma Chicken Pox Diabetes Ear Conditions Epilepsy Heart Disease Measles Allergies (Please Specify) Mumps Nephritis Pneumonia Rheumatic Fever Scarlet Fever Tuberculosis or (TB Contact) Other Has your child had any operations, serious illness, injuries? Please give dates and explain: Does your child wear glasses? Contacts? Hearing Aid? of last dental exam Are there any other physical conditions which might need special attention in school? Please explain: Does your child take medication regularly? Name of medication Signature of Parent/Guardian

2 Immunization Acknowledgement Edna Louise Spear Elementary School Port Jefferson Middle School Earl L. Vandermeulen High School 500 Scraggy Hill Road 350 Old Post Road 350 Old Post Road Port Jefferson, N.Y Port Jefferson, N.Y Port Jefferson, N.Y (631) (631) (631) Dear Parent/Guardian: New York State Education Law and the Regulations of the Commissioner of Education require a physical examination of all children who enter a school district for the first time. It must be completed no more than 12 months prior to, or 30 days after entering school. New York State Public Health Law, Section 2164, mandates that schools cannot permit a child to be admitted unless the parent provides the school with a certificate of immunization or proof from a physician that the child is in the process of receiving the required immunizations. Attached are school forms for your convenience. According to law, these must be completed within 14 days of the child s entry to school. Please complete and sign the enclosed health forms, as well as the acknowledgement below. If you should have any questions or specific health concerns, feel free to call the appropriate school. Parent/Guardian Acknowledgement Student Name_ Grade Phone Pursuant to Public Health Law 2164, I/we the undersigned acknowledge that we have fourteen (14) days (30 days for records from out of NY State) to provide the Port Jefferson School District with our son s/daughter s immunization records. Furthermore, we understand that failure to comply within the allotted time may result in my child s exclusion from school. Parent s/guardian s Signature

3 NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF COMMUNICABLE DISEASE CONTROL IMMUNIZATION PROGRAM Students will need to receive a second dose of measles vaccine if they have not already had two doses. The second dose of measles can be given at the same time as your child s polio and DTP (or DT) booster at your regularly scheduled doctor s office visit. The State Department of Health recommends that the second dose of measles be given in the form of MMR (measles-mumps-rubella) vaccine in order to provide complete protection against all three vaccine-preventable diseases. There is no danger in giving these vaccines to a child who has received them in the past. The following vaccines are required for your child to attend school: 3 doses of diphtheria containing toxoid (usually administered as DTP, DT or Td) 3 doses of oral poliovirus vaccine (OPV) or enhanced inactivated poliovirus vaccine (EIPV) 1 dose of Tdap vaccine as per New York State Immunization Chart 1 dose of mumps vaccine administered after 12 months of age 1 dose of rubella vaccine administered after 12 months of age 2 doses of measles vaccine, the first administered after 12 months of age and the second after 15 months of age 3 doses of Hepatitis B for children born on or after 1/1/93 1 dose of varicella vaccine for children born on or after 1/1/00 3 doses of Haemophilus influenzae type b (Hib) conjugate vaccine for all children less than five years of age who are enrolled in a day care, pre-kindergarten or nursery school. For a child who is 15 months of age or older, it is acceptable to have received a single dose of Haemophilus influenzae type b Conjugate Vaccine at or after the age of 15 months. (Pre-school children only.) NYS PUBLIC HEALTH LAW ARTICLE 13. TITLE 10. SECTION A STATES THAT: Prior to or within 30 days of initial enrollment, schools are required to obtain from the child s parent or guardian, proof that the child has had a blood lead test for children born on or after January The child s cumulative health record must indicate either the date of the lead screening or that information on lead poisoning referral was provided. In some instances doctor-verified disease histories (for mumps and measles) are acceptable as evidence of immunity. Blood tests which show immunity against measles, mumps or rubella are also acceptable as proof of immunity. Religious or medical exemptions to these requirements must be submitted to school officials in writing. If you have any questions, you can call your school nurse, local health department or the State Immunization Program s regional representative in Albany at (518) We wish your child a happy, productive and healthy academic career.

4 Name: Port Jefferson School District 550 Scraggy Hill Rd, Port Jefferson, NY 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). of Birth: HEALTH CERTIFICATE / APPRAISAL FORM School: Gender: M F Grade: IMMUNIZATIONS / HEALTH HISTORY Immunization record attached Sickle Cell Screen: Positive Negative Not done : No immunizations given today PPD: Positive Negative Not done : Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done : Dental Referral Yes No Not done : Significant Medical/Surgical History: See attached Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication: PHYSICAL EXAM of Exam: Urine Results: Sugar: Protein: Height: Weight: _ Blood Pressure: Pulse: Body Mass Index:. Vision - without glasses/contact lenses R L Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L less than 5 th 5 th through 49 th 50 th through 84 th Vision - Near Point R L 85 th through 94 th 95 th through 98 th 99 th and higher Hearing Pass 20 db sc both ears or: R L Tanner: I. II. III. IV. V. Scoliosis: Negative Positive: EXAM ENTIRELY NORMAL CAN PARTICIPATE IN SWIM Specify any abnormality (use reverse of form if needed): MEDICATIONS Medications (list all): None Additional medications listed on reverse of form Name: Name: Dosage/Time: 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 Provider s Signature: Phone: (Stamp below) Provider s Name/Address: Parent Signature: Fax: : 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. 1/12

5 Certificate of Immunization Edna Louise Spear Elementary School Port Jefferson Middle School Earl L. Vandermeulen High School 500 Scraggy Hill Road 350 Old Post Road 350 Old Post Road Port Jefferson, N.Y Port Jefferson, N.Y Port Jefferson, N.Y NAME OF PUPIL DATE OF BIRTH ADDRESS OF PUPIL SEX M / F TEACHER SCHOOL GRADE Section 2164 of the Public Health Law revised September 1989, requires that all children entering or attending school be immunized against Diphtheria, Polio, Measles, German Measles (Rubella), Mumps and Hib. The school is mandated to have written certification on file, therefore, we request that you have your doctor complete this form and return it to the school. Diphtheria, Pertussis, Tetanus (DPT) s: Booster Diphtheria/Tetanus (DT) : Tdap : Measles/Mumps/Rubella (MMR)(Live after one year of age) : 2 nd dose (Recommended between 4 & 6 yrs) : Trivalent Polio (Oral) s: Booster Tuberculin Month Year Result Haemophilus (Hib) (18 months 5 years) s: Hepatitis B (Hep B) s: Varicella Vaccine Month Year Lead Screening (Children born on or after January 01) Month Year Physician s Signature Name: Address: (Please Print) g:\pkk\registration\immunization

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