Secondary Medical Forms - Phillipsburg School District
Secondary Medical Forms - Phillipsburg School District 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.
- Page 2 and 3: Phillipsburg School District 445 Ma
- Page 4 and 5: Phillipsburg School District 445 Ma
- Page 6 and 7: Phillipsburg School District 445 Ma
- Page 8 and 9: New Jersey Department of Education
- Page 10 and 11: 6. Have you ever had or do you curr
- Page 12 and 13: Most recent immunizations and dates
- Page 14 and 15: NOTES TO THE EXAMINING PROVIDER Con
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
<strong>Medical</strong> Information Checklist<br />
1. <strong>School</strong> Health Program Information (keep for reference) 1 page<br />
2. New Student Proof of Physical Exam Requirement Letter 1 page<br />
(complete and return lower portion)<br />
3. Authorization for Obtaining and Sharing Student Health Information 1 page<br />
(complete Section 1 and return;<br />
Section 2 to be completed if further specific information is needed)<br />
4. Student Health History and Emergency Contact New/ Update Form 2 pages<br />
(complete and return)<br />
5. In <strong>School</strong> Medication Administration Authorization 1 page<br />
(physician to complete if needed and parent to return to school nurse)<br />
6. Physician Exam Form-- Doctor to complete and parent to return.<br />
Form depends on Grade level.<br />
a. Elementary <strong>School</strong> – Pre-school through 5 th grade<br />
Universal Child Health Record<br />
2 pages<br />
OR<br />
b. Middle <strong>School</strong>/High <strong>School</strong> – 6 th through 12 th grades<br />
i. HEALTH HISTORY (PART A NJDOE/AAPEF 10/07) 3 pages<br />
Must be filled out by parent/student and presented to physician at exam<br />
ii. PHYSICAL EXAM (PART B NJDOE/AAPEF 10/07)<br />
3 pages<br />
Must be filled out by examining licensed provider at time of exam<br />
iii. Note to examining physician<br />
1 page<br />
iv. Athletic Letter- <strong>School</strong> Sports Information (keep for reference) 1 page<br />
IMMUNIZATION (SHOT) RECORDS MUST BE APPROVED BY THE SCHOOL<br />
NURSE PRIOR TO THE ADMISSION OF EACH STUDENT INTO SCHOOL.
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
Dear Parents:<br />
(Please keep this page for reference)<br />
The school health program in <strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong> is designed to maintain the physical and emotional well being<br />
of all students. To attain this goal, many services are routinely available to all students of the district. However, as with<br />
any school program, we are only effective if full cooperation is received from both students and parents.<br />
The following procedures and services are currently in effect:<br />
MEDICATION: Medication can be administered in school ONLY when the nurse has written instructions from the<br />
student’s physician, including the students name, name of the drug being administered, directions to administer the<br />
drug, and the reason the drug has been prescribed for the student. These instructions (doctors’ orders) must be renewed<br />
every year. Parents must also sign a permission slip for the nurse to administer prescribed medication. THIS LAW<br />
ALSO APPLIES TO ALL OVER THE COUNTER MEDICATIONS, SUCH AS ASPIRIN, TYLENOL, OR<br />
ALLERGY MEDICATIONS. The exception is over the counter eye solutions necessary for daily contact wear, and<br />
cough drops individually carried, if identifiable by manufacturer’s label.<br />
LEAVING SCHOOL BECAUSE OF ACCIDENT OR ILLNESS: When it becomes necessary for a student to leave<br />
school due to accident or illness, a parent/guardian, or their designee, must come to school and sign the student out in<br />
the main office. Please be sure to return the emergency permission form to school indicating person/persons<br />
authorized to pick up your child. Leaving from the health room does not constitute an excused absence from<br />
school.<br />
GYM EXCUSES: Students are required to participate in physical education classes unless they have a current doctor’s<br />
excuse. Please be sure the doctor includes the amount of time that the student will be unable to participate in gym (for<br />
example, one week or one month) or any restrictions, including sports, the student may have.<br />
IMMUNIZATIONS: A constant monitoring of the student’s immunization status is conducted throughout the year in<br />
keeping with New Jersey requirements. If immunizations become due, parents will be notified by letter. The needed<br />
immunization must be received within the allotted time span.<br />
HEALTH SCREENINGS BY SCHOOL NURSE: The nurses conduct several health screenings throughout the year.<br />
Height, weight, blood pressure, pulse, vision, hearing, and scoliosis screenings are done for selected grades during the<br />
year. Parents will be notified if the screenings indicate a need for medical attention.<br />
SCOLIOSIS (Curvature of the spine): New Jersey Law requires all students aged 10 to 18 years old to be examined<br />
for scoliosis every other year beginning in 5 th grade. Parents will be notified by letter if further evaluation is needed. If<br />
you do not want your child examined for any reason, please notify the school in writing within 30 days of receiving this<br />
notice.<br />
PHYSICAL EXAMINATION:<br />
• New student physicals, working paper physicals, and sports physicals should be preformed by the students own<br />
physician (<strong>Medical</strong> Home Office).<br />
• In addition to above requirements the State of New Jersey recommends a physical for each student at least<br />
once during each of the students developmental stages:<br />
o Early Childhood (Pre-school through grade 3)<br />
o Pre-adolescence (Grade 4 through grade 6)<br />
o Adolescence (Grade 7 through grade 12)<br />
• If your child has had a physical during the year, please send a copy and any immunization updates to the nurses<br />
office so that we can document the information on their school health records.<br />
PLEASE COMPLETE THE ENCLOSED EMERGENCY PERMISSION FORM AND STUDENT HEALTH<br />
UPDATE. RETURN THEM TO THE NURSING OFFICE IN YOUR CHILDS SCHOOL. PLEASE INCLUDE<br />
ANY INFORMATION WE MAY NEED TO MAINTAIN A CURRENT CONFIDENTIAL RECORD.<br />
REV. 3/09
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
New Student Physical Exam Requirement<br />
Date ______________<br />
Dear Parent / Guardian :<br />
The New Jersey Department of Education requires every new student entering the<br />
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong> to have a report of a physical exam signed by the doctor submitted to<br />
the school nurse within 30 days of entering school. The exam must have taken place within the past<br />
calendar year. The school district has the right to exclude any student who has not returned the<br />
signed physical exam report 30 days after school entry.<br />
Please sign and date and return lower portion to your child’s school nurse.<br />
Thank you.<br />
----------------------------------------------------------------------------------------------------------<br />
I have received and read the above notice and I understand that proof that a physical exam that has<br />
taken place within the past calendar year must be returned to the school nurse within 30 days of<br />
school entry.<br />
Student Name:_______________________ Date of Birth_____________<br />
Parent/Guardian Signature_______________________ Date_____________<br />
Rev. 4/09
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
Authorization for Obtaining and Sharing Student Health Information.<br />
There are laws that protect the privacy of student health information.<br />
At times the school will need to obtain records from your doctor or other health professional.<br />
This may include but is not limited to: Immunization Records, Medication Orders, <strong>Medical</strong> Excuses<br />
and Releases, Reports of <strong>Medical</strong> Examinations<br />
Health information will be restricted to appropriate staff members directly involved in your child’s<br />
care to avoid any health related problem on a need to know basis.<br />
This may include but is not limited to: information related to allergies, medications and serious<br />
medical conditions such as asthma, diabetes, seizures.<br />
Student Name:_______________________ Date of Birth_____________<br />
Section 1 (please complete for all students)<br />
Authorization for sharing of health information with appropriate school staff:<br />
Parent/Guardian Signature_______________________ Date_____________<br />
Authorization for release of medical records from doctor or institution:<br />
Parent/Guardian Signature_______________________ Date_____________<br />
Section 2 (complete only when further specific information is needed)<br />
Information Requested by <strong>School</strong> Nurse/<strong>School</strong> Physician<br />
_____________________________________________________________________________<br />
Records to be obtained from:<br />
_____________________________________________________________________________<br />
(Name of doctor, practice or institution)<br />
_____________________________________________________________________________<br />
(Address of doctor, practice or institution with City,State and zip)<br />
Records to be returned to: (please circle your child’s school)<br />
<strong>Phillipsburg</strong> Early Childhood Learning Center Barber <strong>School</strong><br />
459 Center Street, <strong>Phillipsburg</strong>, NJ 08865 50 Sargent Avenue, <strong>Phillipsburg</strong>, NJ 08865<br />
Freeman <strong>School</strong><br />
Green Street <strong>School</strong><br />
120 Filmore Street, <strong>Phillipsburg</strong>, NJ 08865 1000 Green Street, <strong>Phillipsburg</strong>, NJ 08865<br />
Andover Morris <strong>School</strong><br />
<strong>Phillipsburg</strong> Middle <strong>School</strong><br />
712 South Main Street, <strong>Phillipsburg</strong>, NJ 08865 525 Warren Street, <strong>Phillipsburg</strong>, NJ 08865<br />
<strong>Phillipsburg</strong> High <strong>School</strong><br />
200 Hillcrest Boulevard, <strong>Phillipsburg</strong>, NJ 08865
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
Student Health History and Emergency Contact Form<br />
Identification:<br />
Student Name:_______________________________ Date of Birth_________ Grade________<br />
Address:_______________________________________ Home Phone#___________________<br />
Family and Emergency Contact:<br />
Father Name<br />
Mother Name<br />
work #____________________cell#_____________<br />
work #____________________cell#_____________<br />
Emergency Contacts: must be able to reach school in 30 minutes or less<br />
1. Name Relationship<br />
Home# Work# Cell#<br />
2. Name Relationship<br />
Home# Work# Cell#<br />
Doctor Name<br />
Dentist Name<br />
Phone# __________________<br />
Phone#_________________<br />
Authorization for Emergency Treatment in <strong>School</strong> or on Field Trips<br />
In case of accident or serious illness when I cannot be contacted, I grant permission for emergency<br />
treatment and procedures as deemed necessary by the physician AND sharing of any medical<br />
information with staff on a need to know basis<br />
Hospital of Choice for Emergency<br />
Parent/Guardian Signature _________________Printed Name _________________Date_______<br />
Does your child have Health Insurance?<br />
Yes, Please provide name of insurance company<br />
No, NJ Family Care provides free or low cost health insurance for uninsured children and<br />
certain low income parents. For more information, please call 800-701-0710 or visit<br />
www.njfamilycare.org to apply online. My name and address may be released to the NJ Family<br />
Care Program to contact me about health insurance.<br />
Signature: Printed Name: Date:<br />
Written consent required pursuant to 20 U.S.C. 1232g (b)(1) and 34 C.F.R. 99.30 (b).<br />
Immunizations:<br />
Please submit any new/ updated record not already on file with the school nurse.
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
Allergies and Dietary Restrictions Explain all “yes” answers below<br />
Food Yes No<br />
If yes, Must have yearly updated “Allergy Action Plan” filed with nurse<br />
Medication Yes No<br />
Bee Sting Yes No<br />
Describe reaction eg rash, difficulty breathing, anaphylaxis<br />
____________________________________________________________________________<br />
______________________________________________________________________________<br />
Medications Taken Regularly Yes No<br />
If medication is to be given in school,<br />
Must have yearly updated “In <strong>School</strong> Medication Authorization” filed with nurse<br />
List Medications and Reason for Use<br />
______________________________________________________________________________<br />
______________________________________________________________________________<br />
General <strong>Medical</strong> Information Explain all “yes” answers below<br />
Hospitalizations: : Yes No<br />
Operations: Yes No<br />
Major Injuries, Broken/Fracture Bones: Yes No<br />
Explain with date and age<br />
____________________________________________________________________________<br />
______________________________________________________________________________<br />
Serious Health Conditions Explain all “yes” answers below:<br />
Asthma Yes No<br />
Exercise induced asthma Yes No<br />
Diabetes Yes No<br />
Heart problems/ High blood pressure Yes No<br />
Kidney/Bladder problems Yes No<br />
Vision/Hearing problems Yes No<br />
Seizures/Epilepsy Yes No<br />
Muscle/ Bone problems Yes No<br />
scoliosis last doctor screening date _________<br />
ADHD/ Mental health problems Yes No<br />
For preschool/elementary school behavior concerns circle below Yes No<br />
Speech difficulty Slow learner Bowel/bladder accidents<br />
Temper tantrums Overactive Inattentive Shy<br />
Fears: noises crowds school animals strangers darkness<br />
Have there been any events in your child’s life that may affect learning Yes No<br />
(example death, divorce)<br />
________________________________________________________________________<br />
Family Social/Health History:<br />
Does anyone smoke in the house Yes No<br />
Please list names and ages of household members<br />
Please explain any family health history that you would like to notify us of:<br />
______________________________________________________________________________
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
IN SCHOOL MEDICATION AUTHORIZATION<br />
New Jersey state law requires a written statement from the physician when a student needs to take a<br />
prescription or over the counter medication during school hours. Medication orders are only<br />
effective for the current school year. Medications must be in the original prescription container<br />
labeled by the pharmacy or in the original over the counter container.<br />
Students with asthma and other potentially life threatening illnesses are permitted to carry and self<br />
administer inhaled or injectable medication for the treatment and prevention of symptoms when<br />
deemed sufficiently responsible and properly educated by the physician and parent/guardian.<br />
After self-medicating with an inhaler (except for prevention), the student is strongly<br />
encouraged to report to the school nurse to have an assessment made regarding the<br />
effectiveness of the medication. Students self-medicating with Epi-Pen must report to school<br />
nurse.<br />
MEDICATION CANNOT BE DISPENSED IN SCHOOL UNTIL A WRITTEN ORDER IS<br />
RECEIVED FROM YOUR PHYSICIAN.<br />
Student’s Name: ______________________________ Grade _____ DOB__________<br />
Phone: home _________________________________work________________________<br />
MEDICATIONS DOSAGE / ROUTE FREQUENCY/<br />
INDICATION<br />
Possible side effects of medication: ___________________________________________<br />
Is student capable of self administration? Please circle: YES NO<br />
Is the student permitted to carry the medication? Please circle: YES NO<br />
For class or field trips? Please circle: As ordered Omit Adjust Schedule ____________<br />
For ½ days Please circle: As ordered Adjust Schedule ____________<br />
___________________________________________________<br />
_____________<br />
Physician’s Signature Phone # Date<br />
Office Stamp<br />
As the parent / guardian of this student, I request he or she be allowed to receive the medication prescribed<br />
above. I hereby agree to indemnify and hold harmless the <strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong>, it’s agents and<br />
employees from any and all liability should any injury occur as a result of the administration of the<br />
medication.<br />
_________________________________ ________ __________________________ ________<br />
Parent / Guardian Signature Date <strong>School</strong> Physician Signature Date<br />
Revised Oct. 2008
New Jersey Department of Education<br />
ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM<br />
Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider<br />
Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA<br />
Part A: HEALTH HISTORY QUESTIONNAIRE<br />
Today’s Date:_____________________<br />
Date of Last Sports Physical: __________________________<br />
Student’s Name: __________________________________ Sex: M F (circle one) Age: ____ Grade: ________<br />
Date of Birth: ____/___/_______ <strong>School</strong>: _____________________________ <strong>District</strong>: _______________________<br />
Sport(s): _____________________________________________________________________<br />
Home Phone: (_____) ___________<br />
Provider Name (<strong>Medical</strong> Home): _______________________________ Phone: _______________________ Fax: ____________<br />
EMERGENCY CONTACT INFORMATION<br />
Name of parent/guardian: _________________________________<br />
Relationship to student: ______________________________<br />
Phone (work): _____________________<br />
Phone (home):______________________________ Phone (cell): ______________<br />
Additional emergency contact: ____________________________<br />
Relationship to student: ______________________________<br />
Phone (work): _____________________<br />
Phone (home):______________________________ Phone (cell): ______________<br />
Directions: Please answer the following questions about the student’s medical history by CIRCLING the correct response. Explain all<br />
“yes” responses on the lines below the questions. Please respond to all questions.<br />
1. Have you ever had, or do you currently have:<br />
a. Restriction from sports for a health related problem? Y / N / Don’t Know<br />
b. An injury or illness since your last exam? Y / N / Don’t Know<br />
c. A chronic or ongoing illness (such as diabetes or asthma)? Y / N / Don’t Know<br />
(1.) An inhaler or other prescription medicine to control asthma? Y / N / Don’t Know<br />
d. Any prescribed or over the counter medications that you take on a regular basis? Y / N / Don’t Know<br />
e. Surgery, hospitalization or any emergency room visit(s)? Y / N / Don’t Know<br />
f. Any allergies to medications? Y / N / Don’t Know<br />
g. Any allergies to bee stings, pollen, latex or foods? Y / N / Don’t Know<br />
(1.) If yes, check type of reaction:<br />
□ Rash □ Hives □ Breathing or other anaphylactic reaction<br />
(2.) Take any medication/Epipen taken for allergy symptoms? (List below.) Y / N / Don’t Know<br />
h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know<br />
i. A blood relative who died before age 50? Y / N / Don’t Know<br />
Explain all “yes” answers here (include relevant dates):<br />
List all medications here:<br />
Medication Name Dosage Frequency<br />
NJDOE/APPEF 10/07<br />
Part A Page 1 of 3<br />
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:<br />
a. Concussion or head injury (including “bell rung” or a “ding”)? Y / N / Don’t Know<br />
b. Memory loss? Y / N / Don’t Know<br />
c. Knocked out? Y / N / Don’t Know<br />
c. A seizure? Y / N / Don’t Know<br />
d. Frequent or severe headaches (With or without exercise)? Y / N / Don’t Know<br />
e. Fuzzy or blurry vision Y / N / Don’t Know<br />
f. Sensitivity to light/noise Y / N / Don’t Know<br />
Explain all “yes” answers here (include relevant dates):<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
3. Have you ever had, or do you currently have, any of the following heart-related conditions:<br />
a. Restriction from sports for heart problems? Y / N / Don’t Know<br />
b. Chest pain or discomfort? Y / N / Don’t Know<br />
c. Heart murmur? Y / N / Don’t Know<br />
d. High blood pressure? Y / N / Don’t Know<br />
e. Elevated cholesterol level? Y / N / Don’t Know<br />
f. Heart infection? Y / N / Don’t Know<br />
g. Dizziness or passing out during or after exercise without known cause? Y / N / Don’t Know<br />
h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know<br />
i. Racing or skipped heartbeats? Y / N / Don’t Know<br />
j. Unexplained difficulty breathing or fatigue during exercise? Y / N / Don’t Know<br />
k. Any family member (blood relative):<br />
(1.) Under age 50 with a heart condition? Y / N / Don’t Know<br />
(2.) With Marfan Syndrome? Y / N / Don’t Know<br />
(3.) Died of a heart problem before age 50? If yes, at what age? _____________________ Y / N / Don’t Know<br />
(4.) Died with no known reason? Y / N / Don’t Know<br />
(5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Don’t Know<br />
Explain all “yes” answers here (include relevant dates):<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions:<br />
a. Vision problems? Y / N / Don’t Know<br />
(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y / N / Don’t Know<br />
b. Hearing loss or problems? Y / N / Don’t Know<br />
(1.) Wear hearing aides or implants? Y / N / Don’t Know<br />
c. Nasal fractures or frequent nose bleeds? Y / N / Don’t Know<br />
d. Wear braces, retainer or protective mouth gear? Y / N / Don’t Know<br />
e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Don’t Know<br />
Explain all “yes” answers here (include relevant dates):<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions:<br />
a. Numbness, a “burner”, “stinger” or pinched nerve? Y / N / Don’t Know<br />
b. A sprain? Y / N / Don’t Know<br />
c. A strain? Y / N / Don’t Know<br />
d. Swelling or pain in muscles, tendons, bones or joints? Y / N / Don’t Know<br />
e. Dislocated joint(s)? Y / N / Don’t Know<br />
f. Upper or lower back pain? Y / N / Don’t Know<br />
g. Fracture(s), stress fracture(s), or broken bone(s)? Y / N / Don’t Know<br />
h. Do you wear any protective braces or equipment? Y / N / Don’t Know<br />
Explain all (yes) answers here (include relevant dates):<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
NJDOE/APPEF 10/07<br />
Part A Page 2 of 3<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
6. Have you ever had or do you currently have any of the following general or exercise related conditions:<br />
a. Difficulty breathing?<br />
(1.) During exercise? Y / N / Don’t Know<br />
(2.) After running one mile? Y / N / Don’t Know<br />
(3.) Coughing, wheezing or shortness of breath in weather changes? Y / N / Don’t Know<br />
(4.) Exercise-induced asthma? Y / N / Don’t Know<br />
i. Controlled with medication? (specify __________________________) Y / N / Don’t Know<br />
ii. Experience dizziness, passing out or fainting?<br />
Y / N / Don’t Know<br />
b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? Y / N / Don’t Know<br />
c. Become tired more quickly than others? Y / N / Don’t Know<br />
d. Any of the following skin conditions:<br />
(1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? Y / N / Don’t Know<br />
(2.) Sun sensitivity? Y / N / Don’t Know<br />
e. Weight gain/loss (of 10 pounds or more)? Y / N / Don’t Know<br />
(1.) Do you want to weigh more or less than you do now? Y / N / Don’t Know<br />
f. Ever had feelings of depression? Y / N / Don’t Know<br />
g. Heat-related problems (dehydration, dizziness, fatigue, headache)? Y / N / Don’t Know<br />
(1.) Heat exhaustion (cool, clammy, damp skin)? Y / N / Don’t Know<br />
(2.) Heat stroke (hot, red, dry skin)? Y / N / Don’t Know<br />
(3.) Muscle cramps? Y / N / Don’t Know<br />
h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Y / N / Don’t Know<br />
Explain all “yes” answers here (include relevant dates):<br />
__________________________________________________________________________________________________________________________<br />
__________________________________________________________________________________________________________________________<br />
_________________________________________________________________________________________________________________________<br />
7. Females only:<br />
Age of onset of menstruation:______ How many menstrual periods in the last twelve (12) months? ________<br />
How many periods missed in the last twelve (12) months?<br />
________<br />
8. Males only:<br />
Have you had any swelling or pain in your testicles or groin?<br />
Y / N / Don’t Know<br />
PARENT/GUARDIAN SIGNATURE<br />
I certify that the information provided herein is accurate to the best of my knowledge as of the date of my<br />
signature.<br />
_______________________________________<br />
Signature, Parent/Guardian or Student Age 18<br />
_________________<br />
Date of Signature:<br />
THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE<br />
EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.<br />
NJDOE/APPEF 10/07<br />
Part A Page 3 of 3<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM<br />
Part B: Physical Evaluation Form<br />
(Completed by the examining licensed provider MD, DO, APN or PA)<br />
-STUDENT INFORMATION-<br />
Student’s Name: __________________________________ Sport(s): _____________________________________________________<br />
Sex: M F (circle one) Age: ________ Grade: _____________ Date of Birth: _________________________________________<br />
Address: ___________________________________________________________________________________________________________<br />
City/State/Zip:________________________________________________ Home Phone: _________________________________________<br />
<strong>School</strong>: _____________________________________________________ <strong>District</strong>: _____________________________________________<br />
Parent/Guardian’s Full Name: __________________________________________________________________________________________<br />
- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-<br />
If conducted by school physician check here □<br />
Name: _______________________________ Phone: __________________________ Fax: _________________<br />
Address: ______________________________<br />
City/State/Zip:_____________________________________________<br />
- FINDINGS OF PHYSICAL EVALUATION -<br />
Height: _________ Weight: _________ Blood Pressure: ______/_______ Pulse: _____bpm.<br />
Vision: R 20/____ L 20/ ____ Corrected: Y / N Contacts: Y / N Glasses: Y / N<br />
INDICATORS NORMAL? ABNORMAL FINDINGS/COMMENTS<br />
General Appearance<br />
YES<br />
Head/Neck<br />
YES<br />
Eyes/Sclera/Pupils<br />
YES<br />
Ears<br />
YES<br />
Gross Hearing<br />
YES<br />
Nose/Mouth/Throat<br />
YES<br />
Lymph Glands<br />
YES<br />
Cardiovascular<br />
YES<br />
Heart Rate<br />
YES<br />
Rhythm<br />
YES<br />
Murmur<br />
ABSENT<br />
If murmur present Standing makes it: Louder Softer No Change<br />
Squatting makes it: Louder Softer No Change<br />
Valsalva makes it: Louder Softer No Change<br />
Femoral Pulses<br />
YES<br />
Lungs: Auscultation/Percussion<br />
YES<br />
Chest Contour<br />
YES<br />
Skin<br />
YES<br />
Abdomen (liver, spleen, masses)<br />
YES<br />
Assessment of physical maturation or YES<br />
Tanner Scale<br />
Testicular Exam (Males Only)<br />
YES<br />
Neck/Back/Spine:<br />
YES<br />
Range of Motion<br />
YES<br />
Scoliosis<br />
ABSENT<br />
Upper Extremities: (ROM, Strength, YES<br />
Stability)<br />
Lower Extremities: (ROM, Strength, YES<br />
Stability)<br />
Neurological: Balance & Coordination YES<br />
Hernia<br />
ABSENT<br />
Evidence of Marfan Syndrome<br />
ABSENT<br />
Part B Page 1 of 4<br />
NJDOE/APPEF 10/07<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
Most recent immunizations and dates administered:<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
Medications currently prescribed, with dose and frequency:<br />
Medication Name Dosage Frequency<br />
Additional observations:<br />
________________________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________________________<br />
_______________________________________________________________________________________________________________________<br />
General Diagnosis: ____________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
___________________________________________________________________________________________________________<br />
General Recommendations:<br />
____________________________________________________________________________________________________________<br />
___________________________________________________________________________________________________________<br />
THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY<br />
THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.<br />
Part B Page 2 of 4<br />
NJDOE/APPEF 10/07<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact)<br />
A. Student is cleared for participation in all sports without restriction.<br />
B. Student is withheld clearance for participation in any sport until evaluation / treatment of:<br />
____________________________________________________________________________________<br />
____________________________________________________________________________________<br />
C. Student is cleared for participation in limited types of sports which exclude the following types of sports<br />
contact: (CHECK ALL THAT APPLY)<br />
___ CONTACT/COLLISION<br />
___ LIMITED CONTACT<br />
___ NON-CONTACT/STRENUOUS<br />
___ NON-CONTACT/NON-STRENUOUS<br />
Due to: __________________________________________________________________________<br />
HISTORY REVIEWED AND STUDENT EXAMINED BY:<br />
Physician’s/Provider’s Stamp:<br />
Primary Care Provider<br />
<strong>School</strong> Physician Provider<br />
License Type:<br />
MD/DO<br />
APN<br />
PA<br />
PHYSICIAN’S/PROVIDER’S SIGNATURE: __________________________________________________ Today’s Date: ______________<br />
HISTORY REVIEWED BY:<br />
Date of Exam: ______________<br />
Name ______________________________________________________<br />
SIGNATURE: __________________________________________________<br />
Today’s Date: _____________<br />
Review Date: ______________<br />
RESERVED FOR SCHOOL DISTRICT USE<br />
Part B Page 3 of 4<br />
NJDOE/APPEF 10/07<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
NOTES TO THE EXAMINING PROVIDER<br />
Conditions requiring clearance before sports participation include, but are not limited to the following:<br />
Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse;<br />
Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly,<br />
Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic<br />
fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.<br />
SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT<br />
Contact/Collision Limited Contact Non-Contact<br />
Strenuous<br />
Non-strenuous<br />
Basketball Baseball Discus Bowling<br />
Diving Cheerleading Javelin Golf<br />
Field Hockey Fencing Shot put<br />
Football High Jump Rowing<br />
Ice Hockey Pole vault Running/Cross Country<br />
Lacrosse Gymnastics Strength Training<br />
Soccer Skiing Swimming<br />
Wrestling Softball Tennis<br />
Volleyball<br />
Track<br />
N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating<br />
approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and<br />
the notification letter become part of the student’s school health record.<br />
Effects of physiologic maneuvers on heart sounds:<br />
Physical Stigmata of Marfan’s Syndrome<br />
Standing Increases murmur of HCM Kyphosis<br />
Decreases murmur of AS, MR<br />
High arched palate<br />
MVP click occurs earlier in systole<br />
Pectus excavatum<br />
Arachnodactyly<br />
Squatting Increases murmur of AS, MR, AI Arm span > height 1.05:1 or greater<br />
Decreases murmur of MCH<br />
Mitral Valve Prolapse<br />
MVP click delayed<br />
Aortic Insufficiency<br />
Myopia<br />
Valsalva Increases murmur of HCM Lenticular dislocation<br />
Decreases murmur of AS, MR<br />
MVP click occurs earlier in systole<br />
HCM = Hypertrophic Cardio Myopathy<br />
AS = Aortic Stenosis<br />
AI = Aortic Insufficiency<br />
MR = Mitral Regugitation<br />
MVP = Mitral Valve Prolapse<br />
Part B Page 4 of 4<br />
NJDOE/APPEF 10/07<br />
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
<strong>Phillipsburg</strong> <strong>School</strong> <strong>District</strong><br />
445 Marshall Street <strong>Phillipsburg</strong>, New Jersey 08865<br />
PHILLIPSBURG HIGH SCHOOL ATHLETICS<br />
200 HILLCREST BLVD.<br />
PHILLIPSBURG, NJ 08865<br />
908-213-2493<br />
Dear Parents/Guardians,<br />
Prior to participation in a school sport, students must provide the following information to the<br />
school nurse or trainer by the due dates below:<br />
• A current physical exam must be completed within 365 days prior to the first<br />
practice of the sport.<br />
• A parent permission and health history questionnaire must be completed within 60<br />
days of the start of each new sport season to advise of any medical problems<br />
experienced since the last medical exam.<br />
• The above information must be reviewed and approved by the school medical<br />
examiner.<br />
Fall season physicals and permission forms are due to the health office by August 3rd.<br />
Fall sports practices may begin as early as August 17 th .<br />
Winter season physicals and permission forms are due to the health office by November 4 th .<br />
Swimming practice starts November 9 th all other sports begin November 27 th .<br />
Spring sport physicals and permission forms are due to the health office by February 19 th . All<br />
spring sport practices start March 5th.<br />
Physical exams and permission forms turned in after the due date may<br />
result in missed practices and tryouts.<br />
PHYSICALS FORMS ARE LOCATED ON THE PHILLPSBURG<br />
HIGH SCHOOL WEB PAGE: www.pburgsd.net<br />
Go to the Athletic Site and click on PHS Physical <strong>Forms</strong> Packet.<br />
<strong>Forms</strong> are also available in the High <strong>School</strong> Athletic Office and Main Office.<br />
Revised 3 09