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.
Chappaqua Central School District
Name: _________________________________________________ Date of Birth: ________________ Gender: M

School: ________________________________________________ Grade: _____ Home Phone: _______________________
Work: (______) ___________________ Cell / Contact Phone: (______) _______________

TB testing: Low Risk/not indicated PPD Date: ________________ Positive Negative
SIGNIFICANT MEDICAL / SURGICAL HISTORY None See attached Other (specify below)


Other: ____________

Specify: _____________________________________________________________________________________________
LIFE THREATENING (Specify: _______________________________) Benadryl prescribed EpiPen prescribed

Medication Administration forms for Benadryl and EpiPen must be completed by physician and attached.
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. _______________________________________________
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.
Parent Section
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: ______________________


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