THE CLEAR VIEW SCHOOL DAY TREATMENT CENTER 2016-2017 BRIARCLIFF MANOR, NEW YORK 10510 of Exam: ANNUAL HEALTH EXAMINATION (To be filled out by physician) Child's Name: of Birth: Physical Height Weight Blood Pressure BMI (Body/Mass Index) Pulse EYES Ophthalmic Vision without glasses: Vision with glasses: R. L. B. R. L. B. EARS Otoscope Has an audiometric examination ever been done: Yes No of last examination TEETH AND GUMS HEAD AND NECK HEART LUNGS ABDOMEN SKIN SKELETAL (scoliosis) NERVOUS SYSTEM Describe history of: Medical History Seizures Asthma Ear condition Frequent colds or sore throats Operations Serious injuries
Child's Name: 2016-2017 ANY HISTORY OF ALLERGY TO FOOD OR MEDICATION (Please include reactions): How long have you known this child? Is this child receiving medication of ANY sort? yes no If YES: Name of drug(s) Amount of dosage Frequency of administration Reason for use Possible reaction to medication Is this child subject to any significant physical defect or physical condition which the school should take into consideration when planning for this child? yes no If YES, please explain: COMMENTS OR RECOMMENDATIONS: This child is free from contagious illness and is cleared for full physical activities. There are NO contraindications to his/her competing in competitive sports. We would be pleased to consult with you about your patient's condition and progress at any time. Physician Signature: Address: Telephone: :
Immunization Record 2016-2017 Child s Name: DOB: : Today s : Fill in the age and date for each immunization child has received: Hepatitis B #1 #2 #3 DTaP (Tetanus) #1 #2 #3 #4 #5 Tdap #1 Hib #1 #2 #3 IPV (OPV) #1 #2 #3 #4 MMR #1 #2 Varicella #1 #2 Pneumonia PCV #1 #2 #3 #4 Meningitis MCV4 #1 #2 Influenza #1 H1N1 #1 HPV #1 PPD #1 Other #1
THE CLEAR VIEW SCHOOL DAY TREATMENT CENTER BRIARCLIFF MANOR, NEW YORK 10510 2016-2017 OVER THE COUNTER MEDICATION PERMISSION FORM Student s name: : Allergies: of Birth: The following medications will be provided by The Clear View School if they have been approved by the child s physician/provider (signature is required) and requested by the guardian; please indicate by checking Yes or No next to medication. Yes/No Drug Name Route Dosage & Schedule Indications Comments Tylenol (or generic ) acetaminophen Advil ( or generic ) ibuprofen Benadryl (or generic) Cepacol lozenges or (generic) (contains Tums or (generic) calcium carbonate Pepto Bismol Oragel/ Anbesol (or generic, contains Hydrocortisone Cream 1% PO ( elixir, or tabs) PO PO (chewable) PO Topical Calagel Topical Medicaine Sting Swabs (contains Topical Antibiotic Ointment Topical Silvadene 1% Topical Pain or Fever Pain or Fever Allergic reactions (hives, insect bites) Sore throat Indigestion, heart burn Upset stomach, nausea, diarrhea, indigestion Toothache, sore gums canker sore Allergic reactions (contact dermatitis, insect bites Poison oak, poison ivy Insect bites, bee stings Superficial cut/ abrasion Burns Call parent/guardian event of fever Call parent/guardian event of fever Call if allergic reaction, respiratory problems / sulfa antibiotic Physician/Provider Signature: Physician/Provider Stamp: (required): : Parent/Guardian Signature :
2016-2017 ANNUAL DENTAL EXAMINATION STUDENT'S NAME BIRTHDATE ADDRESS TEETH: General Condition Temporary Permanent Carious GUMS: General Condition THIS PATIENT: ( ) requires no dental treatment at this time ( ) is under dental treatment at this time ( ) will begin dental treatment at this time ( ) has completed all current dental treatment REMARKS OR RECOMMENDATIONS: Dentist Signature Address Telephone DATE OF EXAMINATION: