CLASS OF

 
STUDENT PHYSICAL INFORMATION AND CONSENT FORM

 

Parent/Guardian:  Please complete and sign the information below

 

STUDENT’S NAME:_________________________________DATE OF BIRTH:______________________

ADDRESS:_____________________________________________________________________________

HOME PHONE: (         )______________STUDENT’S SOCIAL SECURITY #:_________________________

PARENTS’ NAMES:______________________________________________________________________

MOTHER’S BUSINESS NAME AND ADDRESS:________________________________________________

_________________________________________________________________________________­­­­­______

PHONE #: (     )________________________CELL #:____________________________________________

FATHER’S BUSINESS NAME AND ADDRESS:_________________________________________________

_______________________________________________________________________________________

PHONE #: (     )_______________________CELL #:_____________________________________________

PHYSICIAN’S NAME:______________________________________________________________________

ADDRESS:_____________________________________PHONE #:       _____________________________

 

EMERGENCY CONTACT (in case parents cannot be reached):                

 NAME : ________________________________________PHONE:________________________

            

Does the student have allergies or asthma?_________________________________________________

Is the student under any ongoing medical care or treatment? __________________________________

Does the student take any medication? ______________________________________________________

Any special problems of which we should be aware? ___________________________________________

 

 

ÿ Yes   ÿ No    Consent for Emergency Treatment:  In the event that I cannot be reached in an emergency, I give permission for an appropriate medical facility to evaluate my son and provide any necessary medical treatment.  (Every effort is made to contact the parents or emergency contact person first.)

 

ÿ Yes   ÿ No    Consent to Share Information:  The School Nurse has permission to share information provided in this report with appropriate members of the educational team for use in meeting the health and educational needs of the student.  This will be done only on a “need to know” basis, in a confidential manner.  This would include permission for communication between the Health Provider and School Nurse to facilitate this process.

 

ÿ Yes   ÿ No    Consent for Release of Records:  Fordham Preparatory School may provide a copy of the immunization record/medical report to institutions, such as Colleges, transfer schools & Christian Service sites, when requested by the student or parent on behalf of those institutions.

 

Parent/Guardian signature:______________________________________________________

Over
 
Before submitting:  Please make copies of completed form for your son’s future needs (working papers, Christian Service, camps, etc)

 

 

FORDHAM PREPARATORY SCHOOL PHYSICAL EXAMINATION FORM

To be completed by Physician

 

 

STUDENT’S NAME:________________________________DATE EXAM PERFORMED:__________________

HEIGHT:_________      WEIGHT:_________     BLP:_________     VISION:_________   AUDIO:____________

PHYSICAL EXAMINATION:

            NL             AB                                                         NL                AB

            ___           ___               SKIN/SCALP                    ___          ___     MUSCULOSKELETAL/SCOLIOSIS

            ___           ___                HEENT                                        ___         ___     NEUROLOGICAL

            ___           ___               NECK                             ___          ___     ENDOCRINE

            ___           ___                 LUNGS                          ___          ___     G.U.

            ___           ___               HEART                           ___          ___     PSYCHOSOCIAL

            ___           ___               ABDOMEN                      ___          ___     NUTRITION

 

If abnormal, please describe:__________________________________________________________________

f_________________________________________________________________________________________

Allergies or Asthma:                                                                                                      

Current Medical Problems:                                                         

History of illness or surgery:       

Is the student on any medications?  If yes, please list:

 


IMMUNIZATIONS:

MANTOUX (PPD) Tuberculin Skin Test:

Mandated by the NYC Health Dept. for new students entering NYC secondary schools for the first time within ONE year prior to admission.

Date _________     Results_________mm     Chest X-Ray Date_________ Results:______   Medication________

        TB screening is not needed.  No risk factors identified.

 

DPT                  ____/____/____                ____/____/____                ____/____/____            ____/____/____

                        Mo.   Day   Yr.                   Mo.   Day   Yr.                  Mo.   Day   Yr.              Mo.   Day   Yr.

 

DT                    ____/____/____

                         Mo.   Day   Yr.                         

 

Polio                ____/____/____     ____/____/____               ____/____/____            ____/____/____

                        Mo.   Day   Yr.                    Mo.   Day   Yr.                  Mo.   Day   Yr.               Mo.   Day   Yr.     

 

 

MMR                ____/____/____                 ____/____/____            One dose on or after first birthday     

                        Mo.   Day   Yr.                    Mo.   Day   Yr.               Second measles at or after 15 months

                                                                                                                       

HEP B             ____/____/___               ____/____/__             ____/____/___       

                      Mo.   Day   Yr.                    Mo.   Day    Yr.                 Mo.   Day    Yr.           

 

OTHER:  

 

 

ACTIVITIES:     Cleared to participate in gym and sports   FULL:_____                RESTRICTIONS:______   

 

Is this student fit for employment if working papers are requested?    Yes_____   No_____

If yes, this note is valid for 12 months.

 

 

 

____________________________________________                                                          _______________________  

    Physician’s Signature  & Stamp                                                                                                         Date of Exam