Saint Thomas Choir School
PHYSICAL EXAMINATION FORM
2009-2010
(to be completed by Health Care Provider)
Name of Student:
D.O.B.:
Age:
ALLERGIES:______________________________
HEIGHT:
VISION:
CORRECTED:
WEIGHT:
Right Eye
Left Eye
HEARING:
Right Ear
Left Ear
Right Eye
Left Eye
EXT. GENITALIA:EXTREMITIES:
BLOOD PRESSURE:
SKIN:
NOSE AND THROAT:
TUBERCULIN TEST (PPD)
Required by the Dept. of Health for all 1st time
out-of-state entrants to school
TEETH:
HEMOGLOBIN:
HEART:
URINE:
LUNGS:
CHOLESTEROL:
ABDOMEN:
COMMENTS:
Physician Signature & Stamp
Phone Number
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Date of Exam
Name of Student:
IMMUNIZATION RECORD
The New York City/State Department of Health requires that parents supply evidence of the
following immunizations for each child prior to school entrance. Please fill in the spaces with the
date each dose was given. In addition, your doctor must sign this immunization record. No
child may attend school in New York City without this information.
Diphtheria/Tetanus/Pertussis (DPT, DT or Td): 5 (or more) doses required provided 4th dose
was given after 4th birthday
Date 1st:
Date 2nd:
Date 3rd:
Date 4th:
Date 5th:
Td: booster within last 10 years
Date:
H. Influenza Type B. (Hib)
Date 1st:
Date 2nd:
Date 3rd:
Oral Poliovirus (OPV or EIPV):
birthday
Date 1st:
Date 2nd:
Date 4th:
3 doses required provided third dose was given after 4th
Date 3rd:
Date 4th:
Measles/Mumps/Rubella (MMR): 2 doses required after age 12 months
Date 1st:
Date: 2nd:
Varicella Date:
Mantoux PPD (TB)
Date:
Results: Positive Negative
(continued on next page)
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Name of Student:
Hepatitis B vaccine: Recommended at 11-12 years of age for children not previously vaccinated (3
shots required).
Date: 1st:
Date 2nd:
Date 3rd:
Meningococcal meningitis immunization is recommended for residential students in
grades 7 - 12. Please discuss with parent/guardian.
___________________________________________________________________________________________
I have reviewed the student's immunization record and TB test and find them up-to-date
for the age of this child:
Health Care Provider’s Name:_____________________________________________________
Business Address: ________________________________________________________________
Street
City
State
Zip
Telephone: (____)_____________
Signature of health care provider: _________________________________________________
Date: __________________
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Saint Thomas Choir School
PHYSICIAN’S ORDER FORM #1
2009-2010
Authorization for the daily administration of medicines by
St. Thomas Choir School nurses.
St. Thomas Choir School requires a physician's written order and parent or guardian's
authorization for the school nurses to administer prescription and over-the-counter medications,
including vitamins.
Name of Student:
DOB:
Name, dosage & frequency of medication:
____________________________________________________________________________________________
Condition for which the drug is being administered:
____________________________________________________________________________________________
____________________________________________________________________________________________
Relevant side effects to be observed (if any):
If side effects develop, plan of management:
Is this a controlled substance? ______ If yes, DEA number: _____________
Dates for drug to be administered: from _________________ to _________________
mo/day/year
mo/day/year
Signature of Health Care Provider
Date
Business Address
Phone
Parent/Guardian Authorization
I hereby request that the above medication, ordered by the above named health care provider for my
child, be administered by the school nurses. I understand that I must supply the school with the prescribed
medication in the original container in which it was dispensed and it is properly labeled by a physician or
pharmacist. I will provide no more than a 45 school day supply of said medication.
I understand that this medication will be destroyed if it is not taken home within one week following
the termination of the order or beyond the close of school.
Signature of Parent/Guardian
Relationship to child
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Saint Thomas Choir School
PHYSICIAN’S ORDER FORM #2
2009-2010
Authorization for occasional over-the-counter medication administration
by St. Thomas Choir school nurses.
St. Thomas Choir School requires the child’s physician and parent/ guardian’s consent for the school
nurses to periodically administer over-the-counter medications to students for minor ailments such
as toothache, colds, headache, stomach aches, muscle aches and pains, rashes, etc. This will include
medications that you may administer in your own home such as Tylenol, Ibuprofen, Ambersol,
Calamine lotion, cough syrup, Bacitracin ointment, Tums, hydrocortisone cream 1%, Benadryl, etc.
Medication doses will be calculated by the nurse to be weight and age appropriate for each child at
the time of administration.
Name of Student:_______________________________________ DOB:__________________________
I hereby authorize the nurses of St. Thomas Choir School to administer over-the-counter
medications to the above mentioned student at their discretion for minor ailments. Doses shall
be calculated according to weight and age of this child at the time of dispensing.
If the child is currently prescribed a medication which may interact with regular over-thecounter medications, or if the child has a pre-existing condition that prohibits his use of certain
over-the-counter medications, please list them here.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Name of Physician:_____________________________________
Signature of Physician:___________________________________
Name of Parent:_________________________________________
Signature of Parent:______________________________________
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