NEW ADMISSION EXAMINATION FORM

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´╗┐NEW ADMISSION EXAMINATION FORM

DEPT. OF HEALTH & MENTAL HYGIENE -- DEPT. OF EDUCATION

Return in 2 Weeks. Please Print Clearly / Press Hard

TO BE COMPLETED BY THE PARENT OR GUARDIAN

STUDENT LAST NAME

FIRST NAME

MIDDLE

PARENT GUARDIAN FOSTER PARENT

LAST NAME

DISTRICT SCHOOL

NUMBER

FIRST NAME

STUDENT ADDRESS

Public Elem Public JHS/IS

Public H.S. Non-Public

SCHOOL NAME:

HEALTH MESSAGE

STUDENT ID # / OSIS

See Reverse Side

SEX

Male Female

BIRTHDAY MONTH DAY YEAR

RACE/ETHNICITY

Check all that apply

Hispanic Asian Black American Indian White Other

APT/FL ZIP

TELEPHONE NO.

HOME: (

)

WORK: (

)

Annex 1 Annex 2

Does this child have any form of health insurance, Yes

including Medicaid or Child Health Plus?

No

TO BE COMPLETED BY THE HEALTH CARE PROVIDER

Does the student have a past or present medical history of the following:

PRES. PAST NO

PRES. PAST NO

ASTHMA (If present, attach

medication administration form)

Diabetes (If present attach

medication administration form)

Allergies

Congenital Heart Disease Seizures

Cancer Orthopedic Problems Vision Problems Hearing Problems

PRES. PAST NO

Speech Problems Hospitalizations

Surgery Serious Illness Serious Accidents Other Problems/Limitations

If yes to any item, provide:

DATE

DETAILS

PHYSICAL EXAMINATION: HEIGHT

( / ) in

o o ile WEIGHT

lb ( o/o ile) BMI

( / ) o o ile BLOOD PRESSURE

/

GENERAL APPEARANCE (NUTRITIONAL STATUS):

NL AB

HEENT DENTAL STATUS NECK

NL AB

LYMPH NODES LUNGS CARDIOVASCULAR

DESCRIBE ABNORMALITIES:

NL AB

ABDOMEN GENITO URINARY EXTREMITIES

NL AB

BACK SKIN NEURO

NL AB

GROSS MOTOR PSYCHO/SOCIAL DEV. LANGUAGE BEHAVIORAL FINE MOTOR

Hearing

AUDIO/SWEEP THRESHOLD

DATE

RESULTS

PF PF

Vision

DATE

//

FAR

Right

/

Left

/

Both

/

NEAR

/ / /

FUSION COLOR

TB: Only required for students newly entering the NYC school system in Intermediate/Middle/Junior or High School

TB: MANTOUX

(PPD) IMPLANTED READ

DATE

RESULTS

NEGATIVE

MM

POSITIVE

MM

BLOOD-BASED TB TEST RESULTS Name ____________________ POS Date _____________________ NEG

DATE RESULTS

LEAD:

Risk Assessment

DATE DONE //

RESULTS No Risk At Risk

lIf at risk,

do venous lead screening

PF PF

Note: Screening for Amblyopia requires separate distance acuity measurements in each eye and a fusion test.

Chest X-ray //

Normal Abnormal Not Indicated

DATE DONE

//

BCG //

YES NO

On INH //

YES NO

RESULTS

.

IMMUNIZATION -- DATES

Citywide Immunization Registry no.

DPT/DTaP or DT or Td IPV/OPV

Hepatitis B HIB

// // // //

// // // //

// // // //

// //

MMR VZV

// // // //

// // // //

Other

//

//

May provide copy of CIR print out in lieu of completing this section. Must complete CIR Number above.

DIAGNOSES -- If Asthma, indicate severity

Well Child V202

ICD CODE

1.

DATE OF

EXAM:

MONTH

DAY

Physician Signature

YEAR

DOH ONLY

PROVIDER I.D.

TYPE OF EXAMINATION: NAE Current

NAE Prior Year/s

2.

Comments

3. RECOMMENDATIONS/REFERRALS

FULL PHYSICAL ACTIVITY

RESTRICTIONS

Specify limitations and/or special alerts (i.e. allergies, medications, precautions)

Physician Name (Print) Address Telephone

________________________________________

________________________________________

________________________________________

Date

I.D. NUMBER

Reviewed:

//

Name of facility

REVIEWER:

211S (REV. 2/07)

Type of facility

HHC Child Health Clinic HHC Communicare Clinic HHC Hosp. Clinic

Private Practice Comm. Health Center Vol. Hosp. Clinic

Copies: White (Medical Room), Canary (Region)

School-Based Clinic OTHER SHP in School

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