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[PDF File]WIC Medical Referral Form - New York State Department of ...
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DOH-799 (2/18) Page 1of 2 NEW YORK STATE DEPARTMENT OF HEALTH WIC Program WIC Medical Referral Form This form may be used to refer patients to the WIC Program and to communicate changes in patient health information. The information provided on this form will be used by a WIC
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[PDF File]Preparticipation Physical Evaluation History Form - New Jersey
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Preparticipation Physical Evaluation HISTORY FORM (Note: This form is to be ﬁlled out by the patient and parent prior to seeing the physician. The physician should keepa copy of this form in the chart.) ... New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
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[PDF File]Health Care Proxy - New York State Department of Health
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in New York State The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family ... diagnose or treat your physical or mental condition. ... instructions on your Health Care Proxy form or simply discuss them with your agent. Frequently Asked Questions, continued ...
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[PDF File]DEPARTMENT OF HEALTH * THE CITY OF NEW YORK * …
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The attached Sports Examination form is more comprehensive than the form it replaced. The purpose of this new form is to ensure that your child receives a complete physical examination prior to participating in interscholastic sports. The American Academy of Pediatrics, the New York City Department of Health and
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ChiLD & ADOLEsCEnThEALT h ExAMinATiOn FORM Print Clearly
Does the child/adolescent have a past or present medical history of the following? M Asthma (check severity and attach MAF): M Intermittent M Mild Persistent M Moderate Persistent M Severe Persistent M If persistent, check all current medication(s): Quick Relief Medication M Inhaled Corticosteroid Oral Steroid Other Controller None Well-controlledAsthma Control Status M M Poorly Controlled or ...
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[PDF File]Agency Stamp STAFF HEALTH FORM - New York City
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NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE BUREAU OF CHILD CARE STAFF HEALTH FORM Initial employment and every 2 years, a health examination is required for all teaching and non-teaching staff members, including volunteers and students who regularly associate with children. Attach any additional documentation to this form.
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[PDF File]Required NYS School Health Examination Form
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REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11 ; annually for
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[PDF File]PHYSICAL EXAMINATION FORM - New York City
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PHYSICAL EXAMINATION FORM This form must be completed within 90 days prior to submission *In accordance with Federal and State Laws, the New York City Department of Buildings requires that all applicants for licenses/license holders provide their Social Security Number (SSN).
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[PDF File]PLEASE FILL IN REVERSE SIDE - City Tech - New York City ...
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Pu to Section 405.3(b) for the New York State Hospital Codes, the following Statements of Physical Examination is required: Isthere and emotional, mental or physical condition forwhich this student is under medical observation and/or taking medication: { } YES NO If yes",please specify
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SEPTEMBER 2019
ALL STUDENTS ENTERING A NEW YORK CITY (NYC) SCHOOL OR CHILD CARE FOR THE FIRST TIME MUST HAVE A COMPLETE PHYSICAL EXAMINATION AND ALL REQUIRED IMMUNIZATIONS The comprehensive medical examination must be documented on a Child Adolescent Health Examination Form (CH205) and include the following: Weight Body Mass Index Medical History
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New york city physical form