ISLAND TREES PUBLIC SCHOOLS

Transcription

1 Phone: Fox: D 140 SLAND TREES PUBLC SCHOOLS DSTRCT HEALTH SERVCES, Koren M. Stephens, R.N., Dstrct Head Nurse SLAND TREES MEMORAL MDDLE SCHOOL 45 WANTAGH AVENUE SOUTH LEVTTOWN, NEW YORK Dear Parent or Guardan; The New York State Department of Health mandates that every school chld have an annual Health Examnaton n grades Kndergarten, 2nd, 4t\ \ & loth. You are urged to take your chld to your Physcan and Dentst as early as possble before school starts n September. Your Physcan knows your chld and therefore can gve your chld a complete medcal examnaton, vaccnatons and other protectve measures that are necessary. For your convenence and n order to have the Medcal and Dental examnatons done durng the summer months, we are sendng you the necessary forms. Parents please note, t s now requred by the New York State Department of Health, that all chldren enterng the above mentoned grades, have a BM (Body Mass ndex) and percentle completed by ther Physcan. Thank you for your cooperaton. Karen M. Stephens R.N. Dstrct Head Nurse C :x:.!;et1ence ancf Success for _!J_[[ Stucfents

2 School Yeu SLAND TREES PUBLC SCHOOLS LEVTTOWN,!llEW YORK Student's Name Scbool. Addre Room Grade, RECOMMENDATONS OF FAMLY DENTST Tbt student recevd dental treatment Ths student requre no treatment at ths tme Treatment baa been completed Examnng Dentat :(Please Prnt or Stamp> Date Addre Dentst's Spature H'7A 12117

3 ~~.. f, SLAND TREES PUBLC SCHOOLS HEALTH SERVCES [he followng regulatons have been establshed by the School health councl n order to control the spread f communcable dsease, nsure rapd recovery, and guard aganst complcatons. s advsable to keep a chld home from school (and, f necessary, consult your famly physcan), when the hld has any symptoms of llness ncludng the followng:. Elevated temperature or chlls Reddened or dschargng eyes Nausea or vomtng Runny nose enlarged glands skn erupton sore throat coughng earache headache darrhea dzzness rhe school nurse wll requre that a chld who s ll be returned to the home. Transportaton s!!qtprovded h these crcumstances.. ~ chld wth a suspcous skn or scalp condton wll be excluded from school untl seen by a physcan and lreatment prescrbed. A chld wth conjunctvts must be excluded untl a physcan has approved ~ttendance. Chldren returnng to school after recovery from a communcable dsease wll report to the nurse. f there s evdence of conttued dsease, the chld wll not be permtted to reman n school. ~0 CHLD MAY ATTEND SCHOOL USNG CRUTCHES WTHOUT A DOCTOR'S NOTE STATNG THE CHLD CAN ATTEND SCHOOL ON CRUTCHES WTHOUT HAZARD TO HMSELF OR OTHERS. f the )njury necesstates a cast, a note must also state the date the student may return to school. f transportaton s needed, a SEPARATE PHYSCAN'S NOTE should ndcate f the request s for a regular bus or specal transportaton (door to door servce). The note should also nclude the dagnoss and length Of tme for transportaton. STUDENTS ON CRUTCHES MUST HAVE SPECAL TRANSPORTATON. Such :requests should be taken to the health offce n Stokes School.!Upon return from an njury or llness, the student must report drectly to the health Offce and submt a note /from a physcan ndcatng the extent, duraton and lmtaton of physcal actvty or physcal educaton.!students ARE NOT ALLOWED, AT ANY TME, TO CARRY ANY KND OF MEDCATON ON THER PERSON. Any medcaton to be taken durng the school day must be admnstered by the school nurse, be kept n the Health Offce, and be accompaned by a PHYSCAN'S NOTE AND PARENT REQUEST for ts admnstraton. Forms can be obtaned n the Health Offce... Home teachng s avalable. A PHYSCAN'S NOTE requestng home teachng should be taken to the. / Health Offce at Stokes School. A PHYSCAN'S NOTE s requred for the student to return to school. \ Frst ad and frst care for llness or njury that occur n school or on school grounds wll be provded n school. Frst ad s mmedate treatment only. Further care must be provded by the famly or a physcan. Please do not send your chld to the nurse for an opnon regardng an llness or njury. The members of the school health staff are not permtted to offer dagnoss, change dressngs, or treat njures other than to admnster frst ad., These regulatons have been establshed to protect the health and safety of all our school chldren. r 1 HEALTH OFFCES: STOKES MDDLE SCHOOL SPARKE HGH SCHOOL ~~-- ~---

4 Phone: c2164 Fax: SLAND TREES PUBLC SCHOOLS DSTRCT HEALTH SERVCES, Karen M. Stephens, R.N., Dstrct Head Nurse SLAND TREES MEMORAL MDDLE SCHOOL 45 WANTAGH AVENUE SOUTH LEVTTOWN, NEW YORK Student sland Trees Publc Schools mmunzaton Record Date of Brth Dsease Dose #1 Dose #2 Dose #3 Dose #4 Dose #5 OPT, DT (Dpthera, Pertusss,Tetanus Toxod) Tdap Polo (OPV, PV) MMR (Measles, Mumps & Rubella,) HB { Haemophlus nfluenza Type B ) Hepatts "8" Varcella (Chcken Pox) Other Physcans Sgnature ~e([ence and Success for _!1([ Students ~--~---~ ~-~ ~---

5 SLAND TREES PUBLC SCHOOLS MedcaJJAthletc Physcal LAST NAME FRST ~ MALE/FEMALE GRADE DATE Of BRTH LAST TETANUS VACCNE MEDCAL/SURGCAL HSTORY ~ ~ MEDCATONS SPECFY CURRENT CONDTONS: ASTHMA DABETES 1 DABETES 2 - PREHYPERTENSON HYPERTENSON OTHER ALLERGES: HEART RATE ;HEGHT WEGHT BLOO> PRESSURE DATE OF EXAM REQURED BY NYS DEPT. OF HEALTH BODY MASS NDEX: WEGHT STATUS CATEGORY ( BM PERCENTLE): Less than 5th 5th thru 49th 50th thru 84th 85th thru 94th- 95th thru 98th- 99th and hghe;- Heart Eyes Teeth Lungs Orthopedc Skn Ears Lymph Nodes. Abdomen Herna Nervous System Speech Thyrod Throat Gento-Urnary Scoloss: Neg_ Pos _ Ths certfes that the above patent s physcally qualfed to partcpate n the followng categores of competton durng the school year. Please mark wth an "X" all categores allowed. ( ) CONTACT/COLLSON SPORTS (Football, Baseball, Basketball, Soccer, Wrestlng, Lacrosse, Softball) ( ) ENDURANCE ACTVTES (Track, Cross Country, Volleyball) ( ) OTHERS (Bowlng, Golf, Cheerleadng, Kcklne, Feld Events) Reason for dsqualfcaton Referrals: Add any nformaton you feel mght be helpful n understandng or plannng for ths chld : DATE: PHYSCAN'S SGNATURE: STAMP: Ths exam comples wth NYSED requrements and s vald for 12 months, wth the excepton of any llness or njury lastng more than fve days that wll requre revew by prvate physcan or specalst.