NYS School Health Examination Form - To Be Completed by Private Healthcare Provider or School Medical Director

Sep 3, 2026

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NYS School Health Examination Form用于新入学及特定年级学生的体检信息记录，要求由私营医疗机构提供方或学校医疗主任完成，必要时标注未评估项目。表单包含学生基本信息、健康史（过敏、哮喘、癫痫、糖尿病等及相关随附计划）、体格检查与评估、实验室检测与风险筛查，以及视力/听力与脊柱侧弯等筛查结果。另设体育教育与运动参与评估、家族心脏史核对、限制参与类型与其他配套安排，并预留附加信息与处方/计划文件上传记录。

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Student Information

Health History

Physical Examination/Assessment

Screenings

Participation in Physical Education/Sports/Playground/Work

Medications

| REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED BY PRIVATE HEALTHCARE PROVIDER OR SCHOOL MEDICAL DIRECTOR IF AN AREA IS NOT ASSESSED, INDICATE NOT DONE | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 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 interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE)
or Committee on Pre-School Special Education (CPSE) . | | | | | | | | | | | | | | STUDENT INFORMATION | | | | | | | | | | | | | | Name: | | | | | Affirmed Name (if applicable): | | | | | | | DOB: | | Sex Assigned at Birth: ☐ Female ☐ Male | | | | | Gender Identity: ☐ Female ☐ Male ☐ Nonbinary ☐ X | | | | | | | | | School: | | | | | | | | | | Grade: | | Exam Date: | | HEALTH HISTORY | | | | | | | | | | | | | | If yes to any diagnoses below, check all that apply and provide additional information. | | | | | | | | | | | | | | ☐ Allergies | | Type: | | | | | | | | | | | | | | ☐ Medication/Treatment Order Attached | | | | | | | ☐ Anaphylaxis Care Plan Attached | | | | | ☐ Asthma | | Type: ☐ Intermittent ☐ Persistent ☐ Other: | | | | | | | | | | | | | | ☐ Medication/Treatment Order Attached | | | | | | | ☐ Asthma Care Plan Attached | | | | | ☐ Seizures | | Type: | | | | | | | ☐ Date of Last Seizure: | | | | | | | ☐ Medication/Treatment Order Attached | | | | | | | ☐ Seizure Care Plan Attached | | | | | ☐ Diabetes | | Type: ☐ 1 Type: ☐ 2 | | | | | | | | | | | | | | ☐ Medication/Treatment Ordered Attached | | | | | | | ☐ Diabetes Medical Management Plan Attached | | | | | Risk Factors for Diabetes or Pre-Diabetes: Consider screening for T2DM if BMI % > 85% and has 2 or more risk factors: Family History T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother, and/or pre-diabetes. | | | | | | | | | | | | | | BMI kg/m2
Percentile (Weight Status Category) ☐ <5th ☐ 5th-49th ☐ 50th-84th ☐ 85th-94th ☐ 95th-98th ☐ 99th and > | | | | | | | | | | | | | | Hyperlipidemia: ☐ Yes ☐ No ☐ Not Done | | | | | | | Hypertension: ☐ Yes ☐ Not Done | | | | | | | PHYSICAL EXAMINATION/ASSESSMENT | | | | | | | | | | | | | | Height: Weight: BP: Pulse: Respirations: | | | | | | | | | | | | | | Laboratory Testing | | Positive | Negative | Date | | Lead Level
Required for PreK & K | | | | | | Date | | TB-PRN | | ☐ | ☐ | | | ☐ Test Done ☐ Lead Elevated ≥ 5 µg/dL | | | | | | | | Sickle Cell Screen-PRN | | ☐ | ☐ | | | | | | | | | | | ☐ System Review Within Normal Limits
☐ Abnormal Findings–List Other Pertinent Medical Concerns Below (e.g., concussion, mental health, one functioning organ) | | | | | | | | | | | | | | ☐ HEENT
☐ Dental
☐ Mental Health | ☐ Lymph nodes
☐ Cardiovascular
☐ Lungs | | | ☐ Abdomen
☐ Back/Spine/Neck
☐ Genitourinary | | | | ☐ Extremities
☐ Skin
☐ Neurological | | | ☐ Speech
☐ Social Emotional ☐ Musculoskeletal | | | ☐ Assessment/Abnormalities Noted/Recommendations: | | | | | | | | Diagnoses/Problems (list): ICD-10 Code*
*Required only for students with an IEP receiving Medicaid | | | | | | ☐ Additional Information Attached | | | | | | | | | | | | | | Name: | | | | | Affirmed Name (if applicable): | | | | | | DOB: | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | SCREENINGS | | | | | | | | | | | | | Vision & Hearing Screenings Required for New Entrants, PreK or K, 1, 3, 5, 7, & 11 | | | | | | | | | | | | | Vision | With Correction ☐ Yes ☐ No | | | Right | | | | Left | | Referral | Not Done | | Distance Acuity | | | | 20/ | |

FAQs

哪些人需要完成这份NYS学校健康体检表？

私营医疗服务提供方或学校医疗主任需完成。若某些项目未进行评估，应在表内标注“Not Done”。

健康史部分需要填写哪些常见诊断与相关文件？

包括过敏、哮喘、癫痫、糖尿病等。若勾选“Medication/Treatment Order Attached”或护理计划相关选项，应填写并附上相应订单或计划（如Anaphylaxis Care Plan、Asthma Care Plan、Seizure Care Plan、Diabetes Medical Management Plan）。

表单如何评估学生参与体育教育或运动的资格？

需核对家庭心脏史（体育要求），并勾选学生是否可在无限制情况下参与全部活动；如有限制，需说明限制参与的运动类型与其他需要的配套安排，并在必要时使用附加空间说明。

Sep 3, 2026

Upload by Maeve