Flor Ham Park Health Requirements

RIDGEDALE MIDDLE SCHOOL HEALTH OFFICE 71 Ridgedale Avenue Florham Park, New Jersey 07932
TEL: (973) 822-3855 MARK MAJESKI PRINCIPAL
FAX: (973) 822-7963 WEB SITE www.fpks.org/rms
NEW STUDENT HEALTH OFFICE INFORMATION PACKET Welcome to Ridgedale Middle School! The following packet will familiarize you with the health services and required paperwork needed to attend our school. Please contact the School Nurse before your child starts school, if she/he has any special medical needs.
REQUIRED FOR ATTENDANCE:

1. STUDENT REGISTRATION FORMS: (included in Guidance Registration Packet) 2. MEDICAL FORMS: (A.) PHYSICAL EXAMINATION FORM All new students must have a physical upon entrance. The included school official form is to be completed by your physician based on an examination done within the last 365 days. Students without a recent examination should make an appointment and then provide the school nurse with the name of the physician and appointment date. If there is a financial difficulty or other problem, please contact the school nurse for assistance in completing this requirement. (B.) IMMUNIZATION FORM/ Mantoux testing. Immunization records must be supplied before the child enters school. Students entering the 6th grade must have received 3 doses of Hepatitis B vaccine. and those born after 1/1/1997 must have received one dose of Tdap and meningococcal vaccine. See attached, Minimal Immunization Requirements for School Attendance in New Jersey form. A mantoux (tuberculosis test) within the previous six months may be required for certain students depending on yearly revised state criterion. You will also be notified by the nurse, if this test is needed. OTHER INFORMATION INCLUDED IN THE PACKET; Attendance/Roll Call System Policy information. School Policy on Administration of Medication during school hours. Request for Medication forms. (Forms for self-administration of asthma medications can be downloaded at www.fpks.org/rms. (health info) or contact the nurse. Interscholastic Sports Information and Pre-Athletic Participation forms. If you have any questions or concerns, please call me at 973-822-3855 ext 2004 or e-mail me @marian.kentner@fpks.org. Again, welcome and I look forward to having your child (children) in our school. Sincerely, Mrs. Marian Kentner, R.N., B.S.N. School Nurse
Revised: 10/08
FLORHAM PARK PUBLIC SCHOOLS

Florham Park, New Jersey 07932 Phone: (973) 822-3880
PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_________________________________________ Grade:___ Birth Date:__________

Lastt First Middle
Address:_______________________________________________ Phone:___________________ MEDICAL HISTORY Birth Weight:________________ Developmental Disabilities:_______________________________ Interventions:______________________________________________________________________ Indicate dates and results of any of the following evaluations: Vision:_________________ Speech:_______________ Hearing:_____________________________ Spine for Scoliosis:___________________________ Other:_________________________________ Allergies _______________ Hepatitis _______________ Pneumonia ________Asthma _________ Lyme Disease ___________ Strep Infections __________ Convulsions __________ Mononucleosis __________ Urinary Infections ________ Diabetes _________ Otitis Media______ Operations and/or Severe Injuries:_____________________________________________________ Contagious Diseases (Indicate Date): Measles________ Rubella________ Chicken Pox ________ Mumps ________ Other _____________ PHYSICAL EXAMINATION Date of Examination:_________________ Height:_________ Weight:________ BP:_____________ TEETH, MOUTH _________ HEART _________________________ MANTOUX ___________ SKIN _________________ EARS R ________ L ______ NUTRITION __________ EYES R _______ L _______ LUNGS _________________________EXTREMITIES _________ NOSE __________________ ABDOMEN _____________________ FEET _________________ HEAD, NECK ____________ GENITO-URINARY ______________ SPINE _______________ LYMPH GLANDS ________ HERNIA ________________________ COORDINATION ______ THYROID _______________ NERVOUS SYSTEM______________ If the child is on medication, please give details: ________________________________________________________________________________ ________________________________________________________________________________ Are there any physical restrictions? ________________________________________________________________________________ Do you have any further comments or recommendations concerning the child's physical or emotional health which may affect school adjustment?_____________________________________________ Signature of Physician: _____________________________________________________________ Physician's Name: _________________________________________________________________ Address:________________________________________ Phone No.________________________
A faxed copy of this form can be temporarily accepted, the signed original form must follow within 7 days.
Revised: 2/05
Florham Park Public Schools Immunization Form

Name of Student _______________________ Birthdate ________________
The Florham Park Board of Education, in compliance with New Jersey State Law, Chapter 14, requires that children are properly immunized to enter/attend school. Immunization requirements are listed on the reverse of this form. Please have your physician record dates below:
DATE
1. DIPTHERIA, TETANUS, PERTUSSIS Indicate Type of Vaccine (DTaP, Td, DT)
Initial Series
1. 2. 3. 4. 5.
_____________ ____________ _____________ _____________ _____________
2. Tdap 3. ORAL POLIO VACCINE (Indicate OPV or IPV)
1. __________ 1. ____________ 2. ____________ 3. ____________ 1. 2.
4. MMR 5. MEASLES VACCINE (Rubeola) 6. RUBELLA (GERMAN MEASLES) VACCINE 7. MUMPS VACCINE 8. VARICELLA VACCINE 9. HAEMOPHILIS B (Hib) (or Disease Date: )
1._________ 2.__________ 1. 1. ____________ 1.______ 2.________
1. ________ 3. ________ 2. ________ 4. ________ 1. ____________ 2. ____________ 3. ____________ 1.__________ 2.__________ 1. ___________ Most Current 1. ___________ 1.__________ 2.___________ Date: Result:
10. HEPATITIS B
11. PNEUMOCOCCAL 12. MENINGOCOCCAL 13. INFLUENZA 14. HEPATITIS A 15. MANTOUX (Tuberculosis) test within the previous 6 months required for students transferring from countries determined by NJ law. 16. OTHER IMMUNIZATION: Record below TYPE________ Date_____ TYPE______ Date_____
TYPE_______ Date_______
_____________________________________ Physicians Name (Please print) ________________________________ Address
_____________________________________ Physicians Signature __________________________ Telephone
Revised: 3/08
MINIMAL IMMUNIZATION REQUIREMENTS FOR SCHOOL ATTENDANCE IN NEW JERSEY Chapter 14: Immunization for Pupils in School
DISEASE(S) MEETS IMMUNIZATION REQUIREMENTS
(AGE 1-6 YEARS): 4 doses, with one dose given on or after the 4th birthday, OR any 5 doses. (AGE 7-9 YEARS): 3 doses of Td or any previously administered combination of DTP, DTaP, and DT to equal 3 doses. GRADE 6 (or comparable age level for special education programs): 1 dose (AGE 1-6 YEARS): 3 doses, with one dose given on or after the 4th birthday, OR any 4 doses. (AGE 7 or OLDER): Any 3 doses. If born before 1-1-90, 1 dose of a live Measlescontaining vaccine. If born on or after 1-1-90, 2 doses of a live Measles-containing vaccine. If entering a college or university after 9-1-95 and previously unvaccinated, 2 doses of a live Measles-containing vaccine.
COMMENTS
Any child entering pre-school, pre-Kindergarten, or Kindergarten needs a minimum of four doses. Pupils after the seventh birthday should receive adult type Td. DTP/Hib vaccine and DTaP also valid DTP doses. For pupils entering Grade 6 on or after 9-1-08 and born on or after 1-1-97. A child does not need a Tdap dose until FIVE years after the last DTP/DtaP or Td dose. Either Inactivated Polio Vaccine (IPV) or Oral Polio Vaccine (OPV) separately or in combination is acceptable. Polio vaccine is not required of pupils 18 years of age or older. Any child over 15 months of age entering child care, pre-school, or preKindergarten needs a minimum of 1 dose of measles vaccine. Any child entering Kindergarten needs 2 doses. Previously unvaccinated students entering college after 9-1-95 need 2 doses of measles-containing vaccine or any combination containing live measles virus administered after 1968. Documentation of 2 prior doses is acceptable. Laboratory evidence of immunity is also acceptable. Intervals between first and second measles/MMR/MR doses cannot be less than 1 month. Any child over 15 months of age entering child care, pre-school, or preKindergarten needs 1 dose of rubella and mumps vaccine. Each student entering college for the first time after 9-1-95 needs 1 dose of rubella and mumps vaccine or any combination containing live rubella and mumps virus administered after 1968. All children 19 months of age and older enrolled into a child care/pre-school center after 9-1-04 or children born on or after 1-1-98 entering a school for the first time in Kindergarten or Grade 1 need 1 dose of varicella vaccine. Laboratory evidence of immunity, physicians statement or a parental statement of previous varicella disease is also acceptable. Mandated only for children enrolled in child care, pre-school, or pre-Kindergarten. (1) Minimum of 2 doses of Hib vaccine is needed if between the ages of 2-11 months. (2) Minimum of 1 dose of Hib vaccine is needed after the first birthday. DTP/Hib and Hib/Hep B also valid Hib doses.
(1) If a child is between 11-15 years of age and has not received 3 prior doses of Hepatitis B then the child is eligible to receive 2-dose Hepatitis B Adolescent formulation. Laboratory evidence of immunity is also acceptable.
DTaP
Tdap
POLIO
MEASLES
RUBELLA and MUMPS
1 dose of live Mumps-containing vaccine. 1 dose of live Rubella-containing vaccine.
VARICELLA
1 dose on or after first birthday.
HAEMOPHILIS B (Hib)
(AGE 2-11 MONTHS)(1): 2 doses (AGE 12-59 MONTHS)(2): 1 dose
HEPATITIS B
(K-GRADE 12): 3 doses or 2 doses (1)
PNEUMOCOCCAL
(AGE 2-11 MONTHS)(1): 2 doses (AGE 12-59 MONTHS)(2): 1 dose (Entering GRADE 6 (or comparable age level for Special Ed programs): 1 dose (1) (Entering a four-year college or University, previously unvaccinated and residing in a campus dormitory): 1 dose (2) (AGES 6-59 MONTHS): 1 dose ANNUALLY
Mandated only for children enrolled in child care, pre-school, or pre-Kindergarten. (1) Minimum of 2 doses of Pneumococcal vaccine is needed if between the ages of 2-11 months. (2) Minimum of 1 dose of Pneumococcal vaccine is needed after the first birthday. (1) For pupils entering Grade 6 on or after 9-1-08 and born on or after 1-1-97. (2) Previously unvaccinated students entering a four-year college or university after 9-1-04 and who reside in a campus dormitory, need 1 dose of meningococcal vaccine. Documentation of one prior dose is acceptable. For children enrolled in child care, pre-school or pre-Kindergarten on or after 9-1-08. 1 dose to be given between September 1 and December 31 of each year.
MENINGOCOCCAL
INFLUENZA
AGE APPROPRIATE VACCINATIONS (FOR LICENSED CHILD CARE CENTERS/PRE-SCHOOLS)

CHILDS AGE 2-3 Months 4-5 Months 6-7 Months 8-11 Months 12-14 Months 15-17 Months 18 Months-4 Years NUMBER OF DOSES CHILD SHOULD HAVE (BY AGE): 1 dose DTaP, 1 dose Polio, 1 dose Hib, 1 dose PCV7 2 doses DTaP, 2 doses Polio, 2 doses Hib, 2 doses PCV7 3 doses DTaP, 2 doses Polio, 2-3 doses Hib, 2-3 doses PCV7, 1 dose Influenza 3 doses DTaP, 2 doses Polio, 2-3 doses Hib, 2-3 doses PCV7, 1 dose Influenza 3 doses DTaP, 2 doses Polio, 1 dose Hib, 2-3 doses PCV7, 1 dose Influenza 3 doses DTaP, 2 doses Polio, 1 dose MMR, 1 dose Hib, 1 dose PCV7, 1 dose Influenza 4 doses DTaP, 3 doses Polio, 1 dose MMR, 1 dose Hib, 1 dose Varicella, 1 dose PCV7, 1 dose Influenza
PROVISIONAL ADMISSION:
Provisional admission allows a child to enter/attend school but must have a minimum of one dose of each of the required vaccines. Pupils must be actively in the process of completing the series. If a pupil is <5 years of age, they have 17 months to complete the immunization requirements. If a pupil is 5 years of age and older, they have 12 months to complete the immunization requirements.
GRACE PERIODS:
4-day grace period: All vaccines doses administered less than or equal to four days before either the specified minimum age or dose spacing interval shall be counted as valid and shall not require revaccination in order to enter or remain in a school, pre-school or child care facility. 30-day grace period: Those children transferring into a New Jersey school, pre-school, or child care center from out of state/out of country may be allowed a 30day grace period in order to obtain past immunization documentation before provisional status shall begin.
MAR 08
FLORHAM PARK PUBLIC SCHOOLS Florham Park, NJ 07932 SCHOOL HEALTH OFFICES Administration of Medications During School Hours Policy Board of Education Policy states that administration of medication to a student during school hours is permitted only when the pupil's health and continuing attendance in school so require and when the medication is administered in accordance with school policy. Before any medication (prescription or over the counter) may be administered a physician's request and parental request must be completed.. If you have any questions, please contact the health office of the school your child attends. Attendance/Roll Call System Policy All Schools provide a telephone roll call system to check student attendance. This phone system insures the safety of our children by checking that they have arrived safely at school. How the roll call system operates: 1. A telephone answering machine operates 24 hours a day. Absences are to be reported before 8:30 am in the elementary schools and before 7:30 in the middle school. 2. If your child is to be absent or late in arriving, call the school your child attends.(Briarwood 973-822-3884, Brooklake -973-822-3888, Ridgedale -973-822-3855) A recorded message will answer and direct you to press the number to report a student absence. Please be ready to give the following information: A. Your name B. Child's name and grade C. Brief reason for absence and expected date of return D. Press the # button as instructed when done recording 3. This is required each day your child will be absent due to illness. 4. If you know ahead of time that your child will be absent, please notify the office. 5. At 9:00 am all names recorded on the system will be retrieved and compared to the class attendance sheets 6. If an absent child is unaccounted for on the tape, the parents will be notified at home or work. If they cannot be reached, the emergency number you provided will be called. If we are still unable le to locate your child, the Florham Park Police Department and attendance officer will be notified to visit your home. 7. Please recognize that the state of New Jersey is increasing enforcement of unexcused absences truancy. The following reasons listed that are excused absences. Anything not listed WILL be considered unexcused. Students are considered Truant if 10 or more unexcused absences are accrued: a. Student illness b. Appointment with a medical doctor c. Recovery from an accident d. Required court appearance e. Death in the family f. Religious observance g. Such good cause as may be acceptable to the principal
FLORHAM PARK PUBLIC SCHOOLS Florham Park, New Jersey 07932 Phone: (973) 822-3880
* REQUEST FOR MEDICATION ADMINISTRATION BY THE NURSE

PHYSICIANS AUTHORIZATION: In order to protect the health of_________________________, it will be necessary for
(Student's Name)
him/her to have medication during school hours or a school trip, prescribed by me, as follows: Name of medication:______________________________________________________ Mode of administration: _____ Dosage: ______________ Time of day to be given: ________ Purpose of medication/diagnosis: ____________________________________________ (Circle) Daily or PRN? (if PRN how soon can it be repeated)_____________________
Number of days given:_________________or entire school year___________________ Possible side effects/instructions:____________________________________________ I certify that the student is free of any communicable diseases and may return to school: PHYSICIAN'S SIGNATURE:____________________________________DATE:_________ PRINT PHYSICIAN'S NAME:_____________________________PHONE:______________ ADDRESS:___________________________________________________________________
------------------------------------------------------------------
PARENTAL AUTHORIZATION:
I request the school nurse administer the above medication as directed by my physician to my child. I will supply the medication in its original container (prescription or over-the-counter) and notify the school nurse promptly of any change. Please give:___________________________, _________________, ___________________
(Child's name/grade) (Dosage) (Medication)
at___________________A.M./P.M. on the following day(s)__________________________ This medication is being administered for the following reason:______________________
____________________________________________________________________________
(Parent/Guardian's Signature) (Date)
*Authorization is effective for the current school year only. The Board of Education will permit the dispensation of medication in school only when the pupil's health and continuing attendance in school so require and the medication is administered in accordance with the Board's policy. A faxed copy of this form can be temporarily accepted, the signed original form must follow within 7 days.
FLORHAM PARK PUBLIC SCHOOLS RIDGEDALE MIDDLE SCHOOL FLORHAM PARK, N.J. 07932 Tel: 973-822-3855 Fax: 973-822-7963
Dear Parent/Guardian: New Jersey law mandates that every school district provide family life instruction and HIV/AIDS education. The goal of the family life curriculum is to furnish students with a knowledge that supports the development of responsible personal behavior, strengthens and aids in establishing strong family life in the future and contributes to the enrichment of the community. This instruction also helps to develop an understanding of the physical, emotional, social, economic, and physiological aspects of interpersonal relationships, as well as the psychological and cultural foundations of human development, sexuality and reproduction at various stages of growth. Because HIV Infection/AIDS has become a significant health issue in our nation, the Florham Park School District prepared a curriculum that was written by a team of district teachers, nurses, parents and religious community leaders. State guidelines were used in developing educational strategies and methods of instruction, which include the nature, transmission, and prevention of the disease with emphasis on abstinence and healthy decision-making skills. Both the Family Life and HIV/AIDS Curriculums are available for review in any of the schools or board office. Upon written request, a pupil may be excused from any part of the instruction that is in conflict with moral or religious beliefs. Please complete the form below if you DO NOT want your child to participate in this educational opportunity and return it to Mrs. Kentner, the school nurse, by the first day of attending school. Sincerely, Mark Majeski Principal -------------------------------------------------------------______I DO wish my child to participate in the unit on Family Life (Human Growth and Development.) ______I DO NOT wish my child to participate in the unit on Family life (Human Growth and Development.)
_____________________________________ ________________________________________ Students Name/Grade Parent/Guardian Signature/Date
New Jersey Department of Education ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM
Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA Part A: HEALTH HISTORY QUESTIONNAIRE
Todays Date:_____________________
Date of Last Sports Physical: __________________________ Sex: M F (circle one) Age: ____
Grade: ________
Students Name: __________________________________

Date of Birth: ____/___/_______
School: _____________________________
District: _______________________ Home Phone: (_____) ___________
Sport(s): _____________________________________________________________________
Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________
EMERGENCY CONTACT INFORMATION

Name of parent/guardian: _________________________________ Phone (work): _____________________ Relationship to student: ______________________________
Phone (home):______________________________ Phone (cell):
______________
Additional emergency contact: ____________________________ Phone (work): _____________________
Relationship to student: ______________________________

CIRCLING
______________
Directions: Please answer the following questions about the students medical history by yes responses on the lines below the questions. Please respond to all questions. 1. Have you ever had, or do you currently have: a. Restriction from sports for a health related problem? b. An injury or illness since your last exam? c. A chronic or ongoing illness (such as diabetes or asthma)? (1.) An inhaler or other prescription medicine to control asthma? d. Any prescribed or over the counter medications that you take on a regular basis? e. Surgery, hospitalization or any emergency room visit(s)? f. Any allergies to medications? g. Any allergies to bee stings, pollen, latex or foods? (1.) If yes, check type of reaction:
the correct response. Explain all
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Rash Hives Breathing or other anaphylactic reaction (2.) Take any medication/Epipen taken for allergy symptoms? (List below.) Y / N / Dont Know h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Dont Know i. A blood relative who died before age 50? Y / N / Dont Know
Explain all yes answers here (include relevant dates):
List all medications here: Medication Name
Dosage
Frequency
Part A Page 1 of 3
NJDOE/APPEF 10/07 Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
2. Have you ever had, or do you currently have, any of the following head-related conditions: a. Concussion or head injury (including bell rung or a ding)? b. Memory loss? c. Knocked out? c. A seizure? d. Frequent or severe headaches (With or without exercise)? e. Fuzzy or blurry vision f. Sensitivity to light/noise
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Have you ever had, or do you currently have, any of the following heart-related conditions: a. Restriction from sports for heart problems? b. Chest pain or discomfort? c. Heart murmur? d. High blood pressure? e. Elevated cholesterol level? f. Heart infection? g. Dizziness or passing out during or after exercise without known cause? h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? i. Racing or skipped heartbeats? j. Unexplained difficulty breathing or fatigue during exercise? k. Any family member (blood relative): (1.) Under age 50 with a heart condition? (2.) With Marfan Syndrome? (3.) Died of a heart problem before age 50? If yes, at what age? _____________________ (4.) Died with no known reason? (5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions: a. Vision problems? Y / N / Dont Know (1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y / N / Dont Know b. Hearing loss or problems? Y / N / Dont Know (1.) Wear hearing aides or implants? Y / N / Dont Know c. Nasal fractures or frequent nose bleeds? Y / N / Dont Know d. Wear braces, retainer or protective mouth gear? Y / N / Dont Know e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions: a. Numbness, a burner, stinger or pinched nerve? b. A sprain? c. A strain? d. Swelling or pain in muscles, tendons, bones or joints? e. Dislocated joint(s)? f. Upper or lower back pain? g. Fracture(s), stress fracture(s), or broken bone(s)? h. Do you wear any protective braces or equipment? Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all (yes) answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Part A Page 2 of 3
6. Have you ever had or do you currently have any of the following general or exercise related conditions: a. Difficulty breathing? (1.) During exercise? (2.) After running one mile? (3.) Coughing, wheezing or shortness of breath in weather changes? (4.) Exercise-induced asthma? i. Controlled with medication? (specify __________________________) ii. Experience dizziness, passing out or fainting? b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? c. Become tired more quickly than others? d. Any of the following skin conditions: (1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? (2.) Sun sensitivity? e. Weight gain/loss (of 10 pounds or more)? (1.) Do you want to weigh more or less than you do now? f. Ever had feelings of depression? g. Heat-related problems (dehydration, dizziness, fatigue, headache)? (1.) Heat exhaustion (cool, clammy, damp skin)? (2.) Heat stroke (hot, red, dry skin)? (3.) Muscle cramps? h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Explain all yes answers here (include relevant dates):
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
__________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________
7. Females only: Age of onset of menstruation:______
How many menstrual periods in the last twelve (12) months? How many periods missed in the last twelve (12) months?
________ ________
8. Males only: Have you had any swelling or pain in your testicles or groin?
Y / N / Dont Know
PARENT/GUARDIAN SIGNATURE I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature. _______________________________________ Signature, Parent/Guardian or Student Age 18 _________________ Date of Signature:
THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.
Part A Page 3 of 3
ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Part B: Physical Evaluation Form (Completed by the examining licensed provider MD, DO, APN or PA)
-STUDENT INFORMATIONStudents Name: __________________________________ Sport(s): _____________________________________________________ Age: ________ Grade: _____________ Date of Birth: _________________________________________ Sex: M F (circle one) Address: ___________________________________________________________________________________________________________ City/State/Zip:________________________________________________ Home Phone: _________________________________________ School: _____________________________________________________ District: _____________________________________________ Parent/Guardians Full Name: __________________________________________________________________________________________
- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATIONIf conducted by school physician check here
Phone: __________________________ Fax: _________________ City/State/Zip:_____________________________________________
Name: _______________________________ Address: ______________________________
- FINDINGS OF PHYSICAL EVALUATION Height: _________ Weight: _________ Corrected: Y / N Blood Pressure: ______/_______ Pulse: _____bpm. Contacts: Y / N Glasses: Y / N
Vision: R 20/____ L 20/ ____
INDICATORS
General Appearance Head/Neck Eyes/Sclera/Pupils Ears Gross Hearing Nose/Mouth/Throat Lymph Glands Cardiovascular Heart Rate Rhythm Murmur If murmur present
NORMAL?
YES YES YES YES YES YES YES YES YES YES ABSENT
ABNORMAL FINDINGS/COMMENTS
Standing makes it: Squatting makes it: Valsalva makes it: YES YES YES YES YES YES YES YES YES ABSENT YES YES YES ABSENT ABSENT
Louder Louder Louder
Softer Softer Softer
No Change No Change No Change
Femoral Pulses Lungs: Auscultation/Percussion Chest Contour Skin Abdomen (liver, spleen, masses) Assessment of physical maturation or Tanner Scale Testicular Exam (Males Only) Neck/Back/Spine: Range of Motion Scoliosis Upper Extremities: (ROM, Strength, Stability) Lower Extremities: (ROM, Strength, Stability) Neurological: Balance & Coordination Hernia Evidence of Marfan Syndrome
Part B Page 1 of 4
Most recent immunizations and dates administered: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Medications currently prescribed, with dose and frequency: Medication Name Dosage
Frequency
Additional observations: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ General Diagnosis: ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ General Recommendations: ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.
Part B Page 2 of 4
CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact)
A. B.
Student is cleared for participation in all sports without restriction. Student is withheld clearance for participation in any sport until evaluation / treatment of: ____________________________________________________________________________________ ____________________________________________________________________________________ Student is cleared for participation in limited types of sports which exclude the following types of sports contact: (CHECK ALL THAT APPLY)
___ CONTACT/COLLISION ___ LIMITED CONTACT ___ NON-CONTACT/STRENUOUS ___ NON-CONTACT/NON-STRENUOUS
C.
Due to: __________________________________________________________________________
HISTORY REVIEWED AND STUDENT EXAMINED BY:

Primary Care Provider School Physician Provider License Type: MD/DO APN PA
Physicians/Providers Stamp:
PHYSICIANS/PROVIDERS SIGNATURE: __________________________________________________ Todays Date: ______________ Date of Exam: ______________ HISTORY REVIEWED BY: Name ______________________________________________________ SIGNATURE: __________________________________________________ Todays Date: _____________ Review Date: ______________
RESERVED FOR SCHOOL DISTRICT USE
Part B Page 3 of 4
NOTES TO THE EXAMINING PROVIDER

Conditions requiring clearance before sports participation include, but are not limited to the following: Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye. SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT Limited Contact Non-Contact Strenuous Baseball Discus Cheerleading Javelin Fencing Shot put High Jump Rowing Pole vault Running/Cross Country Gymnastics Strength Training Skiing Swimming Softball Tennis Volleyball Track
Contact/Collision Basketball Diving Field Hockey Football Ice Hockey Lacrosse Soccer Wrestling
Non-strenuous Bowling Golf
N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the students participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the students school health record.
Effects of physiologic maneuvers on heart sounds: Standing Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole Increases murmur of AS, MR, AI Decreases murmur of MCH MVP click delayed Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole
Physical Stigmata of Marfans Syndrome Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span > height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation
Squatting
Valsalva
HCM = Hypertrophic Cardio Myopathy AS = Aortic Stenosis AI = Aortic Insufficiency MR = Mitral Regugitation MVP = Mitral Valve Prolapse
Part B Page 4 of 4
BROOKLAKE ELEMENTARY SCHOOL HEALTH OFFICE 235 Brooklake Road Florham Park, New Jersey 07932 TEL: (973) 822-3888 DR. STEVEN CAPONEGRO PRINCIPAL FAX: (973) 822-1577 WEB SITE www.fpks.org/brooklake
NEW STUDENT HEALTH OFFICE INFORMATION PACKET Welcome to Brooklake Elementary School! The following packet of information for the health office was organized to familiarize you with the health services and required paperwork needed to attend our school. Please contact the School Nurse before your child starts school, if she/he has any special medical needs.

1. STUDENT REGISTRATION FORMS: A. STUDENT INFORMATION FORM (included in registration packet) B. HEALTH INFORMATION FORM (included in registration packet) 2. MEDICAL FORMS: A. PHYSICAL EXAMINATION FORM All new students must have a physical upon entrance. The included school official form is to be completed by your physician based on an examination done within the last 365 days. Students without a recent examination should make an appointment and then provide the school nurse with the name of the physician and appointment date. If there is a financial difficulty or other problem, please contact the school nurse for assistance in completing this requirement. B. IMMUNIZATION FORM/ Mantoux testing. By law immunization records must be supplied before the child enters school. See attached, Minimal Immunization Requirements for School Attendance in New Jersey form. In addition, students entering the 6th grade must have received 3 doses of Hepatitis B vaccine and those born after 1/1/1997 must have received one dose of Tdap and meningiococcal vaccine. A mantoux (tuberculosis test) within the previous six months may be required for certain students depending on yearly revised state criterion. You will also be notified by the nurse, if this test is needed. OTHER INFORMATION INCLUDED IN THE PACKET: Attendance/Roll Call System Policy information. Absences must be reported to the Main Office daily. School Policy on Administration of Medication during school hours. Physician and Parent Request for Medication form. (The Asthma Treatment Plan form for asthma medications can be downloaded at www.fpks.org/brooklake. (health info). If you have any questions or concerns, please feel free to call me at 973-822-3888, X. 4003 or e-mail me at marge.aromando@fpks.org. Again, welcome and I look forward to having your child/ children in our school. Sincerely, Mrs. Marguerite Aromando, R.N., BSN Certified School Nurse


Lastt First Middle
Revised: 2/05

DATE
Initial Series
1. 2. 3. 4. 5.
_____________ ____________ _____________ _____________ _____________
1. __________ 1. ____________ 2. ____________ 3. ____________ 1. 2.
1._________ 2.__________ 1. 1. ____________ 1.______ 2.________
10. HEPATITIS B
TYPE_______ Date_______
Revised: 3/08
COMMENTS
DTaP
Tdap
POLIO
MEASLES
RUBELLA and MUMPS
VARICELLA
HAEMOPHILIS B (Hib)
HEPATITIS B
PNEUMOCOCCAL
MENINGOCOCCAL
INFLUENZA

GRACE PERIODS:
MAR 08

(Student's Name)
------------------------------------------------------------------
____________________________________________________________________________
RIDGEDALE MIDDLE SCHOOL HEALTH OFFICE 71 Ridgedale Avenue Florham Park, New Jersey 07932
TEL: (973) 822-3855 MARK MAJESKI PRINCIPAL
FAX: (973) 822-7963 WEB SITE www.fpks.org/rms
NEW STUDENT HEALTH OFFICE INFORMATION PACKET Welcome to Ridgedale Middle School! The following packet will familiarize you with the health services and required paperwork needed to attend our school. Please contact the School Nurse before your child starts school, if she/he has any special medical needs.

1. STUDENT REGISTRATION FORMS: (included in Guidance Registration Packet) 2. MEDICAL FORMS: (A.) PHYSICAL EXAMINATION FORM All new students must have a physical upon entrance. The included school official form is to be completed by your physician based on an examination done within the last 365 days. Students without a recent examination should make an appointment and then provide the school nurse with the name of the physician and appointment date. If there is a financial difficulty or other problem, please contact the school nurse for assistance in completing this requirement. (B.) IMMUNIZATION FORM/ Mantoux testing. Immunization records must be supplied before the child enters school. Students entering the 6th grade must have received 3 doses of Hepatitis B vaccine. and those born after 1/1/1997 must have received one dose of Tdap and meningococcal vaccine. See attached, Minimal Immunization Requirements for School Attendance in New Jersey form. A mantoux (tuberculosis test) within the previous six months may be required for certain students depending on yearly revised state criterion. You will also be notified by the nurse, if this test is needed. OTHER INFORMATION INCLUDED IN THE PACKET; Attendance/Roll Call System Policy information. School Policy on Administration of Medication during school hours. Request for Medication forms. (Forms for self-administration of asthma medications can be downloaded at www.fpks.org/rms. (health info) or contact the nurse. Interscholastic Sports Information and Pre-Athletic Participation forms. If you have any questions or concerns, please call me at 973-822-3855 ext 2004 or e-mail me @marian.kentner@fpks.org. Again, welcome and I look forward to having your child (children) in our school. Sincerely, Mrs. Marian Kentner, R.N., B.S.N. School Nurse
Revised: 10/08


Lastt First Middle
Revised: 2/05

DATE
Initial Series
1. 2. 3. 4. 5.
_____________ ____________ _____________ _____________ _____________
1. __________ 1. ____________ 2. ____________ 3. ____________ 1. 2.
1._________ 2.__________ 1. 1. ____________ 1.______ 2.________
10. HEPATITIS B
TYPE_______ Date_______
Revised: 3/08
COMMENTS
DTaP
Tdap
POLIO
MEASLES
RUBELLA and MUMPS
VARICELLA
HAEMOPHILIS B (Hib)
HEPATITIS B
PNEUMOCOCCAL
MENINGOCOCCAL
INFLUENZA

GRACE PERIODS:
MAR 08

(Student's Name)
------------------------------------------------------------------
____________________________________________________________________________
FLORHAM PARK PUBLIC SCHOOLS RIDGEDALE MIDDLE SCHOOL FLORHAM PARK, N.J. 07932 Tel: 973-822-3855 Fax: 973-822-7963
Dear Parent/Guardian: New Jersey law mandates that every school district provide family life instruction and HIV/AIDS education. The goal of the family life curriculum is to furnish students with a knowledge that supports the development of responsible personal behavior, strengthens and aids in establishing strong family life in the future and contributes to the enrichment of the community. This instruction also helps to develop an understanding of the physical, emotional, social, economic, and physiological aspects of interpersonal relationships, as well as the psychological and cultural foundations of human development, sexuality and reproduction at various stages of growth. Because HIV Infection/AIDS has become a significant health issue in our nation, the Florham Park School District prepared a curriculum that was written by a team of district teachers, nurses, parents and religious community leaders. State guidelines were used in developing educational strategies and methods of instruction, which include the nature, transmission, and prevention of the disease with emphasis on abstinence and healthy decision-making skills. Both the Family Life and HIV/AIDS Curriculums are available for review in any of the schools or board office. Upon written request, a pupil may be excused from any part of the instruction that is in conflict with moral or religious beliefs. Please complete the form below if you DO NOT want your child to participate in this educational opportunity and return it to Mrs. Kentner, the school nurse, by the first day of attending school. Sincerely, Mark Majeski Principal -------------------------------------------------------------______I DO wish my child to participate in the unit on Family Life (Human Growth and Development.) ______I DO NOT wish my child to participate in the unit on Family life (Human Growth and Development.)
_____________________________________ ________________________________________ Students Name/Grade Parent/Guardian Signature/Date
New Jersey Department of Education ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM
Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA Part A: HEALTH HISTORY QUESTIONNAIRE
Todays Date:_____________________
Date of Last Sports Physical: __________________________ Sex: M F (circle one) Age: ____
Grade: ________
Students Name: __________________________________

Date of Birth: ____/___/_______
School: _____________________________
District: _______________________ Home Phone: (_____) ___________
Sport(s): _____________________________________________________________________
Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________
EMERGENCY CONTACT INFORMATION

Name of parent/guardian: _________________________________ Phone (work): _____________________ Relationship to student: ______________________________
______________
Additional emergency contact: ____________________________ Phone (work): _____________________
Relationship to student: ______________________________

CIRCLING
______________
Directions: Please answer the following questions about the students medical history by yes responses on the lines below the questions. Please respond to all questions. 1. Have you ever had, or do you currently have: a. Restriction from sports for a health related problem? b. An injury or illness since your last exam? c. A chronic or ongoing illness (such as diabetes or asthma)? (1.) An inhaler or other prescription medicine to control asthma? d. Any prescribed or over the counter medications that you take on a regular basis? e. Surgery, hospitalization or any emergency room visit(s)? f. Any allergies to medications? g. Any allergies to bee stings, pollen, latex or foods? (1.) If yes, check type of reaction:
the correct response. Explain all
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Rash Hives Breathing or other anaphylactic reaction (2.) Take any medication/Epipen taken for allergy symptoms? (List below.) Y / N / Dont Know h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Dont Know i. A blood relative who died before age 50? Y / N / Dont Know
Explain all yes answers here (include relevant dates):
List all medications here: Medication Name
Dosage
Frequency
Part A Page 1 of 3
2. Have you ever had, or do you currently have, any of the following head-related conditions: a. Concussion or head injury (including bell rung or a ding)? b. Memory loss? c. Knocked out? c. A seizure? d. Frequent or severe headaches (With or without exercise)? e. Fuzzy or blurry vision f. Sensitivity to light/noise
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Have you ever had, or do you currently have, any of the following heart-related conditions: a. Restriction from sports for heart problems? b. Chest pain or discomfort? c. Heart murmur? d. High blood pressure? e. Elevated cholesterol level? f. Heart infection? g. Dizziness or passing out during or after exercise without known cause? h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? i. Racing or skipped heartbeats? j. Unexplained difficulty breathing or fatigue during exercise? k. Any family member (blood relative): (1.) Under age 50 with a heart condition? (2.) With Marfan Syndrome? (3.) Died of a heart problem before age 50? If yes, at what age? _____________________ (4.) Died with no known reason? (5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions: a. Vision problems? Y / N / Dont Know (1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y / N / Dont Know b. Hearing loss or problems? Y / N / Dont Know (1.) Wear hearing aides or implants? Y / N / Dont Know c. Nasal fractures or frequent nose bleeds? Y / N / Dont Know d. Wear braces, retainer or protective mouth gear? Y / N / Dont Know e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Dont Know
Explain all yes answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions: a. Numbness, a burner, stinger or pinched nerve? b. A sprain? c. A strain? d. Swelling or pain in muscles, tendons, bones or joints? e. Dislocated joint(s)? f. Upper or lower back pain? g. Fracture(s), stress fracture(s), or broken bone(s)? h. Do you wear any protective braces or equipment? Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
Explain all (yes) answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Part A Page 2 of 3
6. Have you ever had or do you currently have any of the following general or exercise related conditions: a. Difficulty breathing? (1.) During exercise? (2.) After running one mile? (3.) Coughing, wheezing or shortness of breath in weather changes? (4.) Exercise-induced asthma? i. Controlled with medication? (specify __________________________) ii. Experience dizziness, passing out or fainting? b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? c. Become tired more quickly than others? d. Any of the following skin conditions: (1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? (2.) Sun sensitivity? e. Weight gain/loss (of 10 pounds or more)? (1.) Do you want to weigh more or less than you do now? f. Ever had feelings of depression? g. Heat-related problems (dehydration, dizziness, fatigue, headache)? (1.) Heat exhaustion (cool, clammy, damp skin)? (2.) Heat stroke (hot, red, dry skin)? (3.) Muscle cramps? h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Explain all yes answers here (include relevant dates):
Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know Y / N / Dont Know
__________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________
7. Females only: Age of onset of menstruation:______
How many menstrual periods in the last twelve (12) months? How many periods missed in the last twelve (12) months?
________ ________
8. Males only: Have you had any swelling or pain in your testicles or groin?
Y / N / Dont Know
PARENT/GUARDIAN SIGNATURE I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature. _______________________________________ Signature, Parent/Guardian or Student Age 18 _________________ Date of Signature:
THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.
Part A Page 3 of 3
ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Part B: Physical Evaluation Form (Completed by the examining licensed provider MD, DO, APN or PA)
-STUDENT INFORMATIONStudents Name: __________________________________ Sport(s): _____________________________________________________ Age: ________ Grade: _____________ Date of Birth: _________________________________________ Sex: M F (circle one) Address: ___________________________________________________________________________________________________________ City/State/Zip:________________________________________________ Home Phone: _________________________________________ School: _____________________________________________________ District: _____________________________________________ Parent/Guardians Full Name: __________________________________________________________________________________________
- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATIONIf conducted by school physician check here
Phone: __________________________ Fax: _________________ City/State/Zip:_____________________________________________
Name: _______________________________ Address: ______________________________
- FINDINGS OF PHYSICAL EVALUATION Height: _________ Weight: _________ Corrected: Y / N Blood Pressure: ______/_______ Pulse: _____bpm. Contacts: Y / N Glasses: Y / N
Vision: R 20/____ L 20/ ____
INDICATORS
General Appearance Head/Neck Eyes/Sclera/Pupils Ears Gross Hearing Nose/Mouth/Throat Lymph Glands Cardiovascular Heart Rate Rhythm Murmur If murmur present
NORMAL?
YES YES YES YES YES YES YES YES YES YES ABSENT
ABNORMAL FINDINGS/COMMENTS
Standing makes it: Squatting makes it: Valsalva makes it: YES YES YES YES YES YES YES YES YES ABSENT YES YES YES ABSENT ABSENT
Louder Louder Louder
Softer Softer Softer
No Change No Change No Change
Femoral Pulses Lungs: Auscultation/Percussion Chest Contour Skin Abdomen (liver, spleen, masses) Assessment of physical maturation or Tanner Scale Testicular Exam (Males Only) Neck/Back/Spine: Range of Motion Scoliosis Upper Extremities: (ROM, Strength, Stability) Lower Extremities: (ROM, Strength, Stability) Neurological: Balance & Coordination Hernia Evidence of Marfan Syndrome
Part B Page 1 of 4
Most recent immunizations and dates administered: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Medications currently prescribed, with dose and frequency: Medication Name Dosage
Frequency
Additional observations: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ General Diagnosis: ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ General Recommendations: ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.
Part B Page 2 of 4
CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact)
A. B.
Student is cleared for participation in all sports without restriction. Student is withheld clearance for participation in any sport until evaluation / treatment of: ____________________________________________________________________________________ ____________________________________________________________________________________ Student is cleared for participation in limited types of sports which exclude the following types of sports contact: (CHECK ALL THAT APPLY)
___ CONTACT/COLLISION ___ LIMITED CONTACT ___ NON-CONTACT/STRENUOUS ___ NON-CONTACT/NON-STRENUOUS
C.
Due to: __________________________________________________________________________
HISTORY REVIEWED AND STUDENT EXAMINED BY:

Primary Care Provider School Physician Provider License Type: MD/DO APN PA
Physicians/Providers Stamp:
PHYSICIANS/PROVIDERS SIGNATURE: __________________________________________________ Todays Date: ______________ Date of Exam: ______________ HISTORY REVIEWED BY: Name ______________________________________________________ SIGNATURE: __________________________________________________ Todays Date: _____________ Review Date: ______________
RESERVED FOR SCHOOL DISTRICT USE
Part B Page 3 of 4
NOTES TO THE EXAMINING PROVIDER

Conditions requiring clearance before sports participation include, but are not limited to the following: Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye. SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT Limited Contact Non-Contact Strenuous Baseball Discus Cheerleading Javelin Fencing Shot put High Jump Rowing Pole vault Running/Cross Country Gymnastics Strength Training Skiing Swimming Softball Tennis Volleyball Track
Contact/Collision Basketball Diving Field Hockey Football Ice Hockey Lacrosse Soccer Wrestling
Non-strenuous Bowling Golf
N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the students participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the students school health record.
Effects of physiologic maneuvers on heart sounds: Standing Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole Increases murmur of AS, MR, AI Decreases murmur of MCH MVP click delayed Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole
Physical Stigmata of Marfans Syndrome Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span > height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation
Squatting
Valsalva
HCM = Hypertrophic Cardio Myopathy AS = Aortic Stenosis AI = Aortic Insufficiency MR = Mitral Regugitation MVP = Mitral Valve Prolapse
Part B Page 4 of 4

Flor Ham Park Health Requirements

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RIDGEDALE MIDDLE SCHOOL HEALTH OFFICE 71 Ridgedale Avenue Florham Park, New Jersey 07932

TEL: (973) 822-3855 MARK MAJESKI PRINCIPAL

FAX: (973) 822-7963 WEB SITE www.fpks.org/rms

REQUIRED FOR ATTENDANCE:

FLORHAM PARK PUBLIC SCHOOLS

PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_________________________________________ Grade:___ Birth Date:__________

Florham Park Public Schools Immunization Form

1. DIPTHERIA, TETANUS, PERTUSSIS Indicate Type of Vaccine (DTaP, Td, DT)

_____________ ____________ _____________ _____________ _____________

2. Tdap 3. ORAL POLIO VACCINE (Indicate OPV or IPV)

1. __________ 1. ____________ 2. ____________ 3. ____________ 1. 2.

1._________ 2.__________ 1. 1. ____________ 1.______ 2.________

_____________________________________ Physicians Name (Please print) ________________________________ Address

_____________________________________ Physicians Signature __________________________ Telephone

RUBELLA and MUMPS

1 dose of live Mumps-containing vaccine. 1 dose of live Rubella-containing vaccine.

1 dose on or after first birthday.

(AGE 2-11 MONTHS)(1): 2 doses (AGE 12-59 MONTHS)(2): 1 dose

(K-GRADE 12): 3 doses or 2 doses (1)

AGE APPROPRIATE VACCINATIONS (FOR LICENSED CHILD CARE CENTERS/PRE-SCHOOLS)

* REQUEST FOR MEDICATION ADMINISTRATION BY THE NURSE

_____________________________________ ________________________________________ Students Name/Grade Parent/Guardian Signature/Date

Students Name: __________________________________

District: _______________________ Home Phone: (_____) ___________

Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________

EMERGENCY CONTACT INFORMATION

Phone (home):______________________________ Phone (cell):

Additional emergency contact: ____________________________ Phone (work): _____________________

Relationship to student: ______________________________

Phone (home):______________________________ Phone (cell):

the correct response. Explain all

List all medications here: Medication Name

7. Females only: Age of onset of menstruation:______

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATIONIf conducted by school physician check here

Phone: __________________________ Fax: _________________ City/State/Zip:_____________________________________________

Name: _______________________________ Address: ______________________________

Vision: R 20/____ L 20/ ____

Louder Louder Louder

Softer Softer Softer

No Change No Change No Change

Due to: __________________________________________________________________________

HISTORY REVIEWED AND STUDENT EXAMINED BY:

RESERVED FOR SCHOOL DISTRICT USE

NOTES TO THE EXAMINING PROVIDER

Non-strenuous Bowling Golf

REQUIRED FOR ATTENDANCE:

FLORHAM PARK PUBLIC SCHOOLS

PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_________________________________________ Grade:___ Birth Date:__________

Florham Park Public Schools Immunization Form

1. DIPTHERIA, TETANUS, PERTUSSIS Indicate Type of Vaccine (DTaP, Td, DT)

_____________ ____________ _____________ _____________ _____________

2. Tdap 3. ORAL POLIO VACCINE (Indicate OPV or IPV)

1. __________ 1. ____________ 2. ____________ 3. ____________ 1. 2.

1._________ 2.__________ 1. 1. ____________ 1.______ 2.________

_____________________________________ Physicians Name (Please print) ________________________________ Address

_____________________________________ Physicians Signature __________________________ Telephone

RUBELLA and MUMPS

1 dose of live Mumps-containing vaccine. 1 dose of live Rubella-containing vaccine.

1 dose on or after first birthday.

(AGE 2-11 MONTHS)(1): 2 doses (AGE 12-59 MONTHS)(2): 1 dose

(K-GRADE 12): 3 doses or 2 doses (1)

AGE APPROPRIATE VACCINATIONS (FOR LICENSED CHILD CARE CENTERS/PRE-SCHOOLS)

* REQUEST FOR MEDICATION ADMINISTRATION BY THE NURSE

PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_______________________________________ Grade:_ Birth Date:__________

_______ _ _ _______

1. 1. 2. 3. __ 1. 2.

1._ 2. 1. 1. 1. 2.____

_____ Physicians Name (Please print) Address

___________ Physicians Signature Telephone

_ ____ Students Name/Grade Parent/Guardian Signature/Date

District: _____________________ Home Phone: (_) _________

Provider Name (Medical Home): ___________________ Phone: _ Fax: __

Additional emergency contact: ________ Phone (work): _

Phone: __________________ Fax: _ City/State/Zip:_____________________________________

Name: _ Address:

Vision: R 20/ L 20/

PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_______________________________________ Grade:_ Birth Date:__________

_______ _ _ _______

1. 1. 2. 3. __ 1. 2.

1._ 2. 1. 1. 1. 2.____

_____ Physicians Name (Please print) Address

___________ Physicians Signature Telephone

PHYSICAL EXAMINATION FORM: NEW STUDENTS Name:_______________________________________ Grade:_ Birth Date:__________

_______ _ _ _______

1. 1. 2. 3. __ 1. 2.

1._ 2. 1. 1. 1. 2.____

_____ Physicians Name (Please print) Address

___________ Physicians Signature Telephone

_ ____ Students Name/Grade Parent/Guardian Signature/Date

District: _____________________ Home Phone: (_) _________

Provider Name (Medical Home): ___________________ Phone: _ Fax: __

Additional emergency contact: ________ Phone (work): _

Phone: __________________ Fax: _ City/State/Zip:_____________________________________

Name: _ Address:

Vision: R 20/ L 20/