NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, Interscholastic athletics, working permits, and triennially for the Committee on Special Education (CSE). A dental health certificate is also requested. PHYSICIAN’S HEALTH APPRAISAL FORM Chappaqua Central School District
Name: _________________________________________________ Date of Birth: ________________ Gender: M
School: ________________________________________________ Grade: _____ Home Phone: _______________________
Work: (______) ___________________ Cell / Contact Phone: (______) _______________ IMMUNIZATIONS/HEALTH HISTORY
TB testing: Low Risk/not indicated PPD Date: ________________ Positive Negative SIGNIFICANT MEDICAL / SURGICAL HISTORY None See attached Other (specify below)
Specify: _____________________________________________________________________________________________
LIFE THREATENING (Specify: _______________________________) Benadryl prescribed EpiPen prescribed
Medication Administration forms for Benadryl and EpiPen must be completed by physician and attached. PHYSICAL EXAMINATION
Height: _______________ Weight: _________________ Blood Pressure: ________________ Pulse: ________________
Body Mass Index: (Required): ________% Age____ Vision — without glasses/contact lenses R L
Weight Status Category (BMI Percentile): (Required):
Vision — with glasses/contact lenses R L
Male____________ % Female _____________ % Hearing Pass 20 db sc both ears or: R L EXAM ENTIRELY NORMAL Tanner : I II III IV V Scoliosis: Negative Positive: __________________
Specify any abnormality: __________________________________________________________________________________
1. _________________________________________________ 3. _______________________________________________ 2. _________________________________________________ 4. _______________________________________________ PHYSICAL EDUCATION / SPORTS/ PLAYGROUND
Full participation in all physical education, sports, playground, work & school activities
Limited participation Specify: _________________________________________________________________________
Physician’s Signature: _______________________________________________ Date of exam: __________________
Provider’s Name / Address: _______________________________________________ Phone: _______________________
Provider’s Stamp: (required) Parents of students participating in sports must complete the reverse side. HEALTH HISTORY Parent Section CHAPPAQUA CENTRAL SCHOOL DISTRICT
Name: __________________________________________________________ Date: ___________________________ Address: ________________________________________________________ Grade entering (as of Sept.) ___________
Home Phone: ____________________ Cell / Contact Phone: (______) ________________ Date of Birth: ________________ List the specific sports in which your child will be participating for each season:
Fall: ______________________________ Winter: _____________________________ Spring: __________________________ Required Past Medical History (to be completed by parent / guardian)
Hospitalizations Operations / Surgery Daily Medications Allergies Significant Illnesses and/or Injuries Current conditions being monitored by a physician
Required for Sports Participation - Additional History (to be completed by parent / guardian)
Ever denied full athletic participation? Absence of a paired organ Anemia Asthma / respiratory disorder Concussion (Number ____) Frequent or Severe Headaches Fainting / passing out Heat exhaustion / heat stroke Heart disease - student Heart disease - family Hypertension Mononucleosis Seizures / epilepsy Describe any major musculo-skeletal injury or problem that occurred in the last 3 years
Parent / Guardian Attestation (For All Sports Participation) I declare that the above information is an accurate and true reflection of my child’s condition. Parent /Guardian Signature: ___________________________________________________ Date: ______________________
SYMBIOSELENKUNG (Darmsanierung) Symbioselenkung erfüllt den Zweck, die Darmflora in einen körpergerechten, symbiotischen Zustand zurückzuversetzen. Im Darmtrakt des Menschen leben eine Vielzahl von Kleinstlebewesen, die sich im Laufe der Evolution in Übereinstimmung mit der Nahrung während dieser Entwicklung dort angesiedelt haben. Auch wenn einzelne Stämme dieser Symbionten
Science advances on Environment, Toxicology & Ecotoxicology issues www.chem-tox-ecotox.org “Carcinogenic Chemicals: Classification and Evaluation of Carcinogenic Risk to Humans by International Organizations and the European Union” Prof. A. Valavanidis & Dr. Thomais Vlachogianni Department of Chemistry, University of Athens, University Campus Zog