Secondary Medical Forms - Phillipsburg School District

Phillipsburg School District 

445 Marshall Street Phillipsburg, New Jersey 08865 

Medical Information Checklist 

1. School Health Program Information (keep for reference) 1 page 

2. New Student Proof of Physical Exam Requirement Letter 1 page 

(complete and return lower portion) 

3. Authorization for Obtaining and Sharing Student Health Information 1 page 

(complete Section 1 and return; 

Section 2 to be completed if further specific information is needed) 

4. Student Health History and Emergency Contact New/ Update Form 2 pages 

(complete and return) 

5. In School Medication Administration Authorization 1 page 

(physician to complete if needed and parent to return to school nurse) 

6. Physician Exam Form-- Doctor to complete and parent to return. 

Form depends on Grade level. 

a. Elementary School – Pre-school through 5 th grade 

Universal Child Health Record 

2 pages 

OR 

b. Middle School/High School – 6 th through 12 th grades 

i. HEALTH HISTORY (PART A NJDOE/AAPEF 10/07) 3 pages 

Must be filled out by parent/student and presented to physician at exam 

ii. PHYSICAL EXAM (PART B NJDOE/AAPEF 10/07) 

3 pages 

Must be filled out by examining licensed provider at time of exam 

iii. Note to examining physician 

1 page 

iv. Athletic Letter- School Sports Information (keep for reference) 1 page 

IMMUNIZATION (SHOT) RECORDS MUST BE APPROVED BY THE SCHOOL 

NURSE PRIOR TO THE ADMISSION OF EACH STUDENT INTO SCHOOL.



Dear Parents: 

(Please keep this page for reference) 

The school health program in Phillipsburg School District is designed to maintain the physical and emotional well being 

of all students. To attain this goal, many services are routinely available to all students of the district. However, as with 

any school program, we are only effective if full cooperation is received from both students and parents. 

The following procedures and services are currently in effect: 

MEDICATION: Medication can be administered in school ONLY when the nurse has written instructions from the 

student’s physician, including the students name, name of the drug being administered, directions to administer the 

drug, and the reason the drug has been prescribed for the student. These instructions (doctors’ orders) must be renewed 

every year. Parents must also sign a permission slip for the nurse to administer prescribed medication. THIS LAW 

ALSO APPLIES TO ALL OVER THE COUNTER MEDICATIONS, SUCH AS ASPIRIN, TYLENOL, OR 

ALLERGY MEDICATIONS. The exception is over the counter eye solutions necessary for daily contact wear, and 

cough drops individually carried, if identifiable by manufacturer’s label. 

LEAVING SCHOOL BECAUSE OF ACCIDENT OR ILLNESS: When it becomes necessary for a student to leave 

school due to accident or illness, a parent/guardian, or their designee, must come to school and sign the student out in 

the main office. Please be sure to return the emergency permission form to school indicating person/persons 

authorized to pick up your child. Leaving from the health room does not constitute an excused absence from 

school. 

GYM EXCUSES: Students are required to participate in physical education classes unless they have a current doctor’s 

excuse. Please be sure the doctor includes the amount of time that the student will be unable to participate in gym (for 

example, one week or one month) or any restrictions, including sports, the student may have. 

IMMUNIZATIONS: A constant monitoring of the student’s immunization status is conducted throughout the year in 

keeping with New Jersey requirements. If immunizations become due, parents will be notified by letter. The needed 

immunization must be received within the allotted time span. 

HEALTH SCREENINGS BY SCHOOL NURSE: The nurses conduct several health screenings throughout the year. 

Height, weight, blood pressure, pulse, vision, hearing, and scoliosis screenings are done for selected grades during the 

year. Parents will be notified if the screenings indicate a need for medical attention. 

SCOLIOSIS (Curvature of the spine): New Jersey Law requires all students aged 10 to 18 years old to be examined 

for scoliosis every other year beginning in 5 th grade. Parents will be notified by letter if further evaluation is needed. If 

you do not want your child examined for any reason, please notify the school in writing within 30 days of receiving this 

notice. 

PHYSICAL EXAMINATION: 

• New student physicals, working paper physicals, and sports physicals should be preformed by the students own 

physician (Medical Home Office). 

• In addition to above requirements the State of New Jersey recommends a physical for each student at least 

once during each of the students developmental stages: 

o Early Childhood (Pre-school through grade 3) 

o Pre-adolescence (Grade 4 through grade 6) 

o Adolescence (Grade 7 through grade 12) 

• If your child has had a physical during the year, please send a copy and any immunization updates to the nurses 

office so that we can document the information on their school health records. 

PLEASE COMPLETE THE ENCLOSED EMERGENCY PERMISSION FORM AND STUDENT HEALTH 

UPDATE. RETURN THEM TO THE NURSING OFFICE IN YOUR CHILDS SCHOOL. PLEASE INCLUDE 

ANY INFORMATION WE MAY NEED TO MAINTAIN A CURRENT CONFIDENTIAL RECORD. 

REV. 3/09



New Student Physical Exam Requirement 

Date ______________ 

Dear Parent / Guardian : 

The New Jersey Department of Education requires every new student entering the 

Phillipsburg School District to have a report of a physical exam signed by the doctor submitted to 

the school nurse within 30 days of entering school. The exam must have taken place within the past 

calendar year. The school district has the right to exclude any student who has not returned the 

signed physical exam report 30 days after school entry. 

Please sign and date and return lower portion to your child’s school nurse. 

Thank you. 

---------------------------------------------------------------------------------------------------------- 

I have received and read the above notice and I understand that proof that a physical exam that has 

taken place within the past calendar year must be returned to the school nurse within 30 days of 

school entry. 

Student Name:_______________________ Date of Birth_____________ 

Parent/Guardian Signature_______________________ Date_____________ 

Rev. 4/09



Authorization for Obtaining and Sharing Student Health Information. 

There are laws that protect the privacy of student health information. 

At times the school will need to obtain records from your doctor or other health professional. 

This may include but is not limited to: Immunization Records, Medication Orders, Medical Excuses 

and Releases, Reports of Medical Examinations 

Health information will be restricted to appropriate staff members directly involved in your child’s 

care to avoid any health related problem on a need to know basis. 

This may include but is not limited to: information related to allergies, medications and serious 

medical conditions such as asthma, diabetes, seizures. 

Student Name:_______________________ Date of Birth_____________ 

Section 1 (please complete for all students) 

Authorization for sharing of health information with appropriate school staff: 


Authorization for release of medical records from doctor or institution: 


Section 2 (complete only when further specific information is needed) 

Information Requested by School Nurse/School Physician 

_____________________________________________________________________________ 

Records to be obtained from: 

_____________________________________________________________________________ 

(Name of doctor, practice or institution) 

_____________________________________________________________________________ 

(Address of doctor, practice or institution with City,State and zip) 

Records to be returned to: (please circle your child’s school) 

Phillipsburg Early Childhood Learning Center Barber School 

459 Center Street, Phillipsburg, NJ 08865 50 Sargent Avenue, Phillipsburg, NJ 08865 

Freeman School 

Green Street School 

120 Filmore Street, Phillipsburg, NJ 08865 1000 Green Street, Phillipsburg, NJ 08865 

Andover Morris School 

Phillipsburg Middle School 

712 South Main Street, Phillipsburg, NJ 08865 525 Warren Street, Phillipsburg, NJ 08865 

Phillipsburg High School 

200 Hillcrest Boulevard, Phillipsburg, NJ 08865



Student Health History and Emergency Contact Form 

Identification: 

Student Name:_______________________________ Date of Birth_________ Grade________ 

Address:_______________________________________ Home Phone#___________________ 

Family and Emergency Contact: 

Father Name 

Mother Name 

work #____________________cell#_____________ 

work #____________________cell#_____________ 

Emergency Contacts: must be able to reach school in 30 minutes or less 

1. Name Relationship 

Home# Work# Cell# 

2. Name Relationship 

Home# Work# Cell# 

Doctor Name 

Dentist Name 

Phone# __________________ 

Phone#_________________ 

Authorization for Emergency Treatment in School or on Field Trips 

In case of accident or serious illness when I cannot be contacted, I grant permission for emergency 

treatment and procedures as deemed necessary by the physician AND sharing of any medical 

information with staff on a need to know basis 

Hospital of Choice for Emergency 

Parent/Guardian Signature _________________Printed Name _________________Date_______ 

Does your child have Health Insurance? 

Yes, Please provide name of insurance company 

No, NJ Family Care provides free or low cost health insurance for uninsured children and 

certain low income parents. For more information, please call 800-701-0710 or visit 

www.njfamilycare.org to apply online. My name and address may be released to the NJ Family 

Care Program to contact me about health insurance. 

Signature: Printed Name: Date: 

Written consent required pursuant to 20 U.S.C. 1232g (b)(1) and 34 C.F.R. 99.30 (b). 

Immunizations: 

Please submit any new/ updated record not already on file with the school nurse.



Allergies and Dietary Restrictions Explain all “yes” answers below 

Food Yes No 

If yes, Must have yearly updated “Allergy Action Plan” filed with nurse 

Medication Yes No 

Bee Sting Yes No 

Describe reaction eg rash, difficulty breathing, anaphylaxis 

____________________________________________________________________________ 

______________________________________________________________________________ 

Medications Taken Regularly Yes No 

If medication is to be given in school, 

Must have yearly updated “In School Medication Authorization” filed with nurse 

List Medications and Reason for Use 

______________________________________________________________________________ 

______________________________________________________________________________ 

General Medical Information Explain all “yes” answers below 

Hospitalizations: : Yes No 

Operations: Yes No 

Major Injuries, Broken/Fracture Bones: Yes No 

Explain with date and age 

____________________________________________________________________________ 

______________________________________________________________________________ 

Serious Health Conditions Explain all “yes” answers below: 

Asthma Yes No 

Exercise induced asthma Yes No 

Diabetes Yes No 

Heart problems/ High blood pressure Yes No 

Kidney/Bladder problems Yes No 

Vision/Hearing problems Yes No 

Seizures/Epilepsy Yes No 

Muscle/ Bone problems Yes No 

scoliosis last doctor screening date _________ 

ADHD/ Mental health problems Yes No 

For preschool/elementary school behavior concerns circle below Yes No 

Speech difficulty Slow learner Bowel/bladder accidents 

Temper tantrums Overactive Inattentive Shy 

Fears: noises crowds school animals strangers darkness 

Have there been any events in your child’s life that may affect learning Yes No 

(example death, divorce) 

________________________________________________________________________ 

Family Social/Health History: 

Does anyone smoke in the house Yes No 

Please list names and ages of household members 

Please explain any family health history that you would like to notify us of: 

______________________________________________________________________________



IN SCHOOL MEDICATION AUTHORIZATION 

New Jersey state law requires a written statement from the physician when a student needs to take a 

prescription or over the counter medication during school hours. Medication orders are only 

effective for the current school year. Medications must be in the original prescription container 

labeled by the pharmacy or in the original over the counter container. 

Students with asthma and other potentially life threatening illnesses are permitted to carry and self 

administer inhaled or injectable medication for the treatment and prevention of symptoms when 

deemed sufficiently responsible and properly educated by the physician and parent/guardian. 

After self-medicating with an inhaler (except for prevention), the student is strongly 

encouraged to report to the school nurse to have an assessment made regarding the 

effectiveness of the medication. Students self-medicating with Epi-Pen must report to school 

nurse. 

MEDICATION CANNOT BE DISPENSED IN SCHOOL UNTIL A WRITTEN ORDER IS 

RECEIVED FROM YOUR PHYSICIAN. 

Student’s Name: ______________________________ Grade _____ DOB__________ 

Phone: home _________________________________work________________________ 

MEDICATIONS DOSAGE / ROUTE FREQUENCY/ 

INDICATION 

Possible side effects of medication: ___________________________________________ 

Is student capable of self administration? Please circle: YES NO 

Is the student permitted to carry the medication? Please circle: YES NO 

For class or field trips? Please circle: As ordered Omit Adjust Schedule ____________ 

For ½ days Please circle: As ordered Adjust Schedule ____________ 

___________________________________________________ 

_____________ 

Physician’s Signature Phone # Date 

Office Stamp 

As the parent / guardian of this student, I request he or she be allowed to receive the medication prescribed 

above. I hereby agree to indemnify and hold harmless the Phillipsburg School District, it’s agents and 

employees from any and all liability should any injury occur as a result of the administration of the 

medication. 

_________________________________ ________ __________________________ ________ 

Parent / Guardian Signature Date School Physician Signature Date 

Revised Oct. 2008

New Jersey Department of Education 

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM 

Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider 

Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA 

Part A: HEALTH HISTORY QUESTIONNAIRE 

Today’s Date:_____________________ 

Date of Last Sports Physical: __________________________ 

Student’s Name: __________________________________ Sex: M F (circle one) Age: ____ Grade: ________ 

Date of Birth: ____/___/_______ School: _____________________________ District: _______________________ 

Sport(s): _____________________________________________________________________ 

Home Phone: (_____) ___________ 

Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________ 

EMERGENCY CONTACT INFORMATION 

Name of parent/guardian: _________________________________ 

Relationship to student: ______________________________ 

Phone (work): _____________________ 

Phone (home):______________________________ Phone (cell): ______________ 

Additional emergency contact: ____________________________ 

Relationship to student: ______________________________ 

Phone (work): _____________________ 

Phone (home):______________________________ Phone (cell): ______________ 

Directions: Please answer the following questions about the student’s medical history by CIRCLING the correct response. Explain all 

“yes” responses on the lines below the questions. Please respond to all questions. 

1. Have you ever had, or do you currently have: 

a. Restriction from sports for a health related problem? Y / N / Don’t Know 

b. An injury or illness since your last exam? Y / N / Don’t Know 

c. A chronic or ongoing illness (such as diabetes or asthma)? Y / N / Don’t Know 

(1.) An inhaler or other prescription medicine to control asthma? Y / N / Don’t Know 

d. Any prescribed or over the counter medications that you take on a regular basis? Y / N / Don’t Know 

e. Surgery, hospitalization or any emergency room visit(s)? Y / N / Don’t Know 

f. Any allergies to medications? Y / N / Don’t Know 

g. Any allergies to bee stings, pollen, latex or foods? Y / N / Don’t Know 

(1.) If yes, check type of reaction: 

□ Rash □ Hives □ Breathing or other anaphylactic reaction 

(2.) Take any medication/Epipen taken for allergy symptoms? (List below.) Y / N / Don’t Know 

h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know 

i. A blood relative who died before age 50? Y / N / Don’t Know 

Explain all “yes” answers here (include relevant dates): 

List all medications here: 

Medication Name Dosage Frequency 

NJDOE/APPEF 10/07 

Part A Page 1 of 3 

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

2. Have you ever had, or do you currently have, any of the following head-related conditions: 

a. Concussion or head injury (including “bell rung” or a “ding”)? Y / N / Don’t Know 

b. Memory loss? Y / N / Don’t Know 

c. Knocked out? Y / N / Don’t Know 

c. A seizure? Y / N / Don’t Know 

d. Frequent or severe headaches (With or without exercise)? Y / N / Don’t Know 

e. Fuzzy or blurry vision Y / N / Don’t Know 

f. Sensitivity to light/noise Y / N / Don’t Know 


____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

3. Have you ever had, or do you currently have, any of the following heart-related conditions: 

a. Restriction from sports for heart problems? Y / N / Don’t Know 

b. Chest pain or discomfort? Y / N / Don’t Know 

c. Heart murmur? Y / N / Don’t Know 

d. High blood pressure? Y / N / Don’t Know 

e. Elevated cholesterol level? Y / N / Don’t Know 

f. Heart infection? Y / N / Don’t Know 

g. Dizziness or passing out during or after exercise without known cause? Y / N / Don’t Know 

h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know 

i. Racing or skipped heartbeats? Y / N / Don’t Know 

j. Unexplained difficulty breathing or fatigue during exercise? Y / N / Don’t Know 

k. Any family member (blood relative): 

(1.) Under age 50 with a heart condition? Y / N / Don’t Know 

(2.) With Marfan Syndrome? Y / N / Don’t Know 

(3.) Died of a heart problem before age 50? If yes, at what age? _____________________ Y / N / Don’t Know 

(4.) Died with no known reason? Y / N / Don’t Know 

(5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Don’t Know 


____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions: 

a. Vision problems? Y / N / Don’t Know 

(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y / N / Don’t Know 

b. Hearing loss or problems? Y / N / Don’t Know 

(1.) Wear hearing aides or implants? Y / N / Don’t Know 

c. Nasal fractures or frequent nose bleeds? Y / N / Don’t Know 

d. Wear braces, retainer or protective mouth gear? Y / N / Don’t Know 

e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Don’t Know 


____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions: 

a. Numbness, a “burner”, “stinger” or pinched nerve? Y / N / Don’t Know 

b. A sprain? Y / N / Don’t Know 

c. A strain? Y / N / Don’t Know 

d. Swelling or pain in muscles, tendons, bones or joints? Y / N / Don’t Know 

e. Dislocated joint(s)? Y / N / Don’t Know 

f. Upper or lower back pain? Y / N / Don’t Know 

g. Fracture(s), stress fracture(s), or broken bone(s)? Y / N / Don’t Know 

h. Do you wear any protective braces or equipment? Y / N / Don’t Know 

Explain all (yes) answers here (include relevant dates): 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 




6. Have you ever had or do you currently have any of the following general or exercise related conditions: 

a. Difficulty breathing? 

(1.) During exercise? Y / N / Don’t Know 

(2.) After running one mile? Y / N / Don’t Know 

(3.) Coughing, wheezing or shortness of breath in weather changes? Y / N / Don’t Know 

(4.) Exercise-induced asthma? Y / N / Don’t Know 

i. Controlled with medication? (specify __________________________) Y / N / Don’t Know 

ii. Experience dizziness, passing out or fainting? 

Y / N / Don’t Know 

b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? Y / N / Don’t Know 

c. Become tired more quickly than others? Y / N / Don’t Know 

d. Any of the following skin conditions: 

(1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? Y / N / Don’t Know 

(2.) Sun sensitivity? Y / N / Don’t Know 

e. Weight gain/loss (of 10 pounds or more)? Y / N / Don’t Know 

(1.) Do you want to weigh more or less than you do now? Y / N / Don’t Know 

f. Ever had feelings of depression? Y / N / Don’t Know 

g. Heat-related problems (dehydration, dizziness, fatigue, headache)? Y / N / Don’t Know 

(1.) Heat exhaustion (cool, clammy, damp skin)? Y / N / Don’t Know 

(2.) Heat stroke (hot, red, dry skin)? Y / N / Don’t Know 

(3.) Muscle cramps? Y / N / Don’t Know 

h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Y / N / Don’t Know 


__________________________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________________________ 

_________________________________________________________________________________________________________________________ 

7. Females only: 

Age of onset of menstruation:______ How many menstrual periods in the last twelve (12) months? ________ 

How many periods missed in the last twelve (12) months? 

________ 

8. Males only: 

Have you had any swelling or pain in your testicles or groin? 

Y / N / Don’t Know 

PARENT/GUARDIAN SIGNATURE 

I certify that the information provided herein is accurate to the best of my knowledge as of the date of my 

signature. 

_______________________________________ 

Signature, Parent/Guardian or Student Age 18 

_________________ 

Date of Signature: 

THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE 

EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM. 




ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM 

Part B: Physical Evaluation Form 

(Completed by the examining licensed provider MD, DO, APN or PA) 

-STUDENT INFORMATION- 

Student’s Name: __________________________________ Sport(s): _____________________________________________________ 

Sex: M F (circle one) Age: ________ Grade: _____________ Date of Birth: _________________________________________ 

Address: ___________________________________________________________________________________________________________ 

City/State/Zip:________________________________________________ Home Phone: _________________________________________ 

School: _____________________________________________________ District: _____________________________________________ 

Parent/Guardian’s Full Name: __________________________________________________________________________________________ 

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION- 

If conducted by school physician check here □ 

Name: _______________________________ Phone: __________________________ Fax: _________________ 

Address: ______________________________ 

City/State/Zip:_____________________________________________ 

- FINDINGS OF PHYSICAL EVALUATION - 

Height: _________ Weight: _________ Blood Pressure: ______/_______ Pulse: _____bpm. 

Vision: R 20/____ L 20/ ____ Corrected: Y / N Contacts: Y / N Glasses: Y / N 

INDICATORS NORMAL? ABNORMAL FINDINGS/COMMENTS 

General Appearance 

YES 

Head/Neck 

YES 

Eyes/Sclera/Pupils 

YES 

Ears 

YES 

Gross Hearing 

YES 

Nose/Mouth/Throat 

YES 

Lymph Glands 

YES 

Cardiovascular 

YES 

Heart Rate 

YES 

Rhythm 

YES 

Murmur 

ABSENT 

If murmur present Standing makes it: Louder Softer No Change 

Squatting makes it: Louder Softer No Change 

Valsalva makes it: Louder Softer No Change 

Femoral Pulses 

YES 

Lungs: Auscultation/Percussion 

YES 

Chest Contour 

YES 

Skin 

YES 

Abdomen (liver, spleen, masses) 

YES 

Assessment of physical maturation or YES 

Tanner Scale 

Testicular Exam (Males Only) 

YES 

Neck/Back/Spine: 

YES 

Range of Motion 

YES 

Scoliosis 

ABSENT 

Upper Extremities: (ROM, Strength, YES 

Stability) 

Lower Extremities: (ROM, Strength, YES 

Stability) 

Neurological: Balance & Coordination YES 

Hernia 

ABSENT 

Evidence of Marfan Syndrome 

ABSENT 

Part B Page 1 of 4 



Most recent immunizations and dates administered: 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

Medications currently prescribed, with dose and frequency: 

Medication Name Dosage Frequency 

Additional observations: 

________________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

_______________________________________________________________________________________________________________________ 

General Diagnosis: ____________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

General Recommendations: 

____________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY 

THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION. 




CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact) 

A. Student is cleared for participation in all sports without restriction. 

B. Student is withheld clearance for participation in any sport until evaluation / treatment of: 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

C. Student is cleared for participation in limited types of sports which exclude the following types of sports 

contact: (CHECK ALL THAT APPLY) 

___ CONTACT/COLLISION 

___ LIMITED CONTACT 

___ NON-CONTACT/STRENUOUS 

___ NON-CONTACT/NON-STRENUOUS 

Due to: __________________________________________________________________________ 

HISTORY REVIEWED AND STUDENT EXAMINED BY: 

Physician’s/Provider’s Stamp: 

Primary Care Provider 

School Physician Provider 

License Type: 

MD/DO 

APN 

PA 

PHYSICIAN’S/PROVIDER’S SIGNATURE: __________________________________________________ Today’s Date: ______________ 

HISTORY REVIEWED BY: 

Date of Exam: ______________ 

Name ______________________________________________________ 

SIGNATURE: __________________________________________________ 

Today’s Date: _____________ 

Review Date: ______________ 

RESERVED FOR SCHOOL DISTRICT USE 




NOTES TO THE EXAMINING PROVIDER 

Conditions requiring clearance before sports participation include, but are not limited to the following: 

Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; 

Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, 

Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic 

fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye. 

SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT 

Contact/Collision Limited Contact Non-Contact 

Strenuous 

Non-strenuous 

Basketball Baseball Discus Bowling 

Diving Cheerleading Javelin Golf 

Field Hockey Fencing Shot put 

Football High Jump Rowing 

Ice Hockey Pole vault Running/Cross Country 

Lacrosse Gymnastics Strength Training 

Soccer Skiing Swimming 

Wrestling Softball Tennis 

Volleyball 

Track 

N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating 

approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and 

the notification letter become part of the student’s school health record. 

Effects of physiologic maneuvers on heart sounds: 

Physical Stigmata of Marfan’s Syndrome 

Standing Increases murmur of HCM Kyphosis 

Decreases murmur of AS, MR 

High arched palate 

MVP click occurs earlier in systole 

Pectus excavatum 

Arachnodactyly 

Squatting Increases murmur of AS, MR, AI Arm span > height 1.05:1 or greater 

Decreases murmur of MCH 

Mitral Valve Prolapse 

MVP click delayed 

Aortic Insufficiency 

Myopia 

Valsalva Increases murmur of HCM Lenticular dislocation 

Decreases murmur of AS, MR 

MVP click occurs earlier in systole 

HCM = Hypertrophic Cardio Myopathy 

AS = Aortic Stenosis 

AI = Aortic Insufficiency 

MR = Mitral Regugitation 

MVP = Mitral Valve Prolapse 






PHILLIPSBURG HIGH SCHOOL ATHLETICS 

200 HILLCREST BLVD. 

PHILLIPSBURG, NJ 08865 

908-213-2493 

Dear Parents/Guardians, 

Prior to participation in a school sport, students must provide the following information to the 

school nurse or trainer by the due dates below: 

• A current physical exam must be completed within 365 days prior to the first 

practice of the sport. 

• A parent permission and health history questionnaire must be completed within 60 

days of the start of each new sport season to advise of any medical problems 

experienced since the last medical exam. 

• The above information must be reviewed and approved by the school medical 

examiner. 

Fall season physicals and permission forms are due to the health office by August 3rd. 

Fall sports practices may begin as early as August 17 th . 

Winter season physicals and permission forms are due to the health office by November 4 th . 

Swimming practice starts November 9 th all other sports begin November 27 th . 

Spring sport physicals and permission forms are due to the health office by February 19 th . All 

spring sport practices start March 5th. 

Physical exams and permission forms turned in after the due date may 

result in missed practices and tryouts. 

PHYSICALS FORMS ARE LOCATED ON THE PHILLPSBURG 

HIGH SCHOOL WEB PAGE: www.pburgsd.net 

Go to the Athletic Site and click on PHS Physical Forms Packet. 

Forms are also available in the High School Athletic Office and Main Office. 

Revised 3 09

Secondary Medical Forms - Phillipsburg School District

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