MARIA REGINA HIGH SCHOOL 500 WEST HARTSDALE AVENUE

HARTSDALE, NY 10530

REGISTRATION MEDICAL AND HEALTH PACKAGE

COMPLETE: IN FULL AND RE.TURN TO THE SCHOOL NURSE.

MAY' t 1, 2011

1. Health History ___completed by parent

2. Report of Medical Exam completed by doctor Include in the physical exam performed by your doctor the following:

• Immunizations with complete dates - month, date and year Varicella vaccine and/or titer and lor had chicken pox - DOCTOR MUST sign

• BMI Survey The physical exam must be within the year (If your child had a physical on September 8, 2010, we will accept it for May 11,2011. In September, please send the 2011 form.

3. Sport Physical Exam completed by parent & doctor Attached is the ONLY form that will be accepted by the school.

******Sport Physical and Report of Medical Exam are not interchangeable********

4. Medication Form completed by parent & doctor ONLY if student requires medication while attending school; over the counter medication such as Advil/TylenoIJMidol, Benadryl, and Antibiotics etc. will be dispensed in school only with this form. Bring the medicine to the Nurse's Office on the first day of school.

5. Self Medication Authorization Form completed by parent & doctor ONLY if student requires MDt Epi-pen, insulin and/or insulin pump etc.

6. Dental Health Form ___completed by dentist

7. Allergy Form ___completed by parent & doctor

8. Emergency Card ___completed by parent

I value your time in finishing this form completely and promptly. H I can be of further assistance please do not hesitate to call 914-761-3300 ext. 3.

Sincerely, Sari Lugay, MSN, RN

The Greenburgh Central School District No.7 provides Maria Regina High School with the services ofa school nurse (RN). She is on the premise on a daily basis when school is in session.

~o W. 'HA'RTSD~LE AVE.

RARTSDAL'€";· ... NeY'I' 'fb~~" IOM~

Student's Last Name

. . -.olace of BirthDate of Birth Sex Moth:!,•••", ~ A~~WEBS..... ' - ,.

A. BIRTH HISTOR'P!.EASI: vlr\\lL

""YES DATES D. OPERATIONS PL~~- YES NONO DATES YES YES NONO 1 Tonsila, adenoids

YES

1. Was mother ill dUring pregancy 2 AppendixNO YES NO2 Was birth delivery normal

YES 3. Hernia YES NONO3 Was child premature 4. Ear YES NO4. Birth weight

DATES 5 Other Operations (Explain):

YES

B. HAS YOUR CHILD HAD: YES NO

NOChickenpox Diphtheria NOYES

Encephalitis NO E. HAS YOUR CHILD HAD ANY

German measles

YES

Serous accidents YES NO YES NO

Fractured (broken) bones NOYES YES NOLyme Disease Measles Serious head injury NOYES YES NO

Meningitis If YES, give details NOYES

NOMumps YES

Ostemomyelitis (bone infection) YES NO F. HAS YOUR CHILD BEEN A HOSPITAL PATIENT FOR ANY OTHER

Pheumonia YES NO CONDITION If YES, give details:

Polio YES NO

Rheumatic fever NOYES G.. HAS YOUR CHILD EVER BEEN EXPOSED TO ANYONE WITH TUBERCULOSIS? If YES, give details:

Sca rlet fever NO

Strep Throat

YES

NO If YES, give result of: chest xYES patch other ray test skin

Tuberculosis NOYES

Whooping cough NOYES H.HAS YOUR CHILD EVER BEEN TESTED YES NO RESUL FOR BLOOD LEAD LEVEL Other (specify as, tumor, blood disease, anemia):

DATESYES I. HAS ANYONE IN YOUR IMMEDIATE C. DOES YOUR CHILD HAVE: NO YES NO DATES <:::1\, v U /\r\.

ASTHMAAsthma (Wheezing) NOYES YES NO

Blindness CONVULSIONSYES NO YES NO

Cerebral palsy DIABETESNOYES YES NO

HEART "ATTACK" Chorea (SI. Vitus' dance) NOYES YES NO

Convulsion due to other causes HEARING LOSSYES NO YES NO

Cystic fibroSIS TuberculosisYES NO YES NO

Diabetes (sugar) NERVOUS TROUBLtNOYES YES NO

Epilepsy (Fits, Seizures) IF YES, indicate relation (0 your child

Kidney trouble

YES NO

NO

Migraine headache

YES

Is the condition under medical care? YES NO

Muscular dystropy YES NO J. ARE THERE ANY HEALTH CONDITION IN YOUR FAMILY THAT ARE A PROMBLEM TO YOU AND/OR YOUR CHILD? If YES, EXPLAIN:

Sicle cell NO

Other "chronic disease"

YES

Specify

Heath History, rev 8/04

I

GREENBURGH CENTRAL SCHOOL DISTRICT No.7 HEALTH HISTORY REGISTRATION FORMSWERS

1"11r:A~~ r.IRCLEAN ~ACl: r.IRCLE1"11 "" -"IM. ARE THERE ANY PILLS, MEDICINES, OR-­r~":H'AS YOUR CHILD HAD ANY TROUBLE \ YES__..i_~~O ~- '{c5 NUINJECTiONS THAT GIVE YOUR CHILD A REACTiON

h::yes crossing or turning in? YES I NO ~~ ~~ ~n .~,.~

Infamed eyes or styes? NO What are they?YES Does your child take any pits, medicines or treatments, Having to hold things close to see? NOYES YES NOeither on a regular or part-time basis?

Tonsils or adenoids? NOYES Bleeding from any place? NO What are they?YES

Frquent nosebleeds? YES NON. HAS YOUR DAUGHTER STARTED HER PERIODSYES NO

Swollen glands? NOYES Age at onset?

Teeth? NO Any trouble with them? YES More than 3 or 4 colds a year? YES NONO What trouble?YES

Being overweight? YES NONO Take medication? YES

Being underweight? YES NO What medication?

Being thirsty all the time? YES NO Has this normal process been sufficiently explained to her. YES NO

Poor appetite? YES NO O. DOES YOUR CHILD USE ANY OF THESE AIDS? YES NO

HAving to hold things close to see? YES NO Contact lens YES NO

Poor appetite? YES NO Eyeglasses YES NO

Sleeping poorly? YES NO Hearing Aid YES NO

Frequent headaches? YES NO Crutches YES NO

Dizziness or fainting spells? YES NO Braces for arm or leg YES NO

Tremper outbursts? YES NO Wheelchair YES NO

Being moody? YES NO Dental plate YES NO

Showing unusal behaVior? YES NO Other, specify

Skin disease, irritation, or rash? YES NO

Chest Pains?

Persistent cough or wheezing? YES

YES

NO

NO

P. HAS YOUR CHILD HAD ANY OF THE FOLLOWING _. ­

DISORDERS: YES NO

Spitting up blood? YES NO Hearing YES NO

Tiring easily? YES NO earache YES NO

Stomachaches? YES NO drainages YES NO

Vomiting? YES NO Q. DOES YOUR CHILD HAVE ANY PHYSICAL DEFECT THAT MAY Bowl movements being different? YES NO INTERFERE WITH HIS SPEECH? NOYES

Hernia (Rupture) NOYES R. ARE THERE ANY OTHER HEALTH PROBLEMS Frequent urination? YESNO NO INOT ALREADY MENTIONED? IF, YES,PLEASE EXPLAI YES Burning on urination? YES NO

Painful joints? NOYES S. DO YOU CONSIDER YOUR CHILD'S HEALi GOOD

Swollen or stiff Joints? T. CAN YOUR CHILD PARTICIPATE IN ALL SCHOOLNOYES

IF NO, EXPLAIN: YES NOWalking? Staggering? NOYES

Poor posture? NOYES U. ARE YOU IN NEED OF HELP ABOUT YOUR CHILD'S HEALTH Feet? NO AS IT APPLIES TO SCHOOL? YES

L.DOES YOUR CHILD HAVE ANY If YES to any of the above, please write a brief statement. Give NOYESALLERGIES (INCLUDING BEE AND doctor's name, if under his care or observation.

,~--~

PhysicianWhat are they?

TelephoneARE THERE ANY FOODS YOUR CHILD SHOULD NOT EAT?

PARENT'S SIGNATURE What are they?

Heam nlstory, rev tj/U4

FAIR POOR

YES NO

YES NO

GREENBURGH CENTRAL SCHOOL DISTRICT NO.7 MARIA REGINA HIGH SCHOOL 475 WEST HARTSDALE AVENUE 500 WEST HARTSDALE AVENUE I;lARTSDALE, NEW YORK 10530 HARTSDALE, NY 10530

REPORT OF MEDICAL EXAM

NAME _ GRADE__

HT: WT: BM! 0/0 -­ BIP 1\1IF D.O.B. -_/_-_/

SCOLIOSIS: () present () NOT present VISION: R L: HEARING: R L:

Serious illness, injury, or surgery in the last year? _

ALLERGIES: _

CURRENT MEDICATION: _

PHYSICAL EXAM INCLUDES: Nutritional status, Skin, Scalp, Hands, Feet, Eyes, Ears, Nose, Teeth, Tonsils, Lymph Glands, Thyroid Glands, Heart, Lungs, Breast, Abdomen., Genito-Urinary, Hernia exam, Neurological and Emotional status is NORMAL except as indicated _

Known or suspected disability: _

IMMUNIZAnONS DATE/1 DATEi2 DATE/3 DATE/4 DATE/5 BOSSTRIX DPT/TDIDTAP T-Dap I POLIO-OPV I I I

IPV RIB I 1YIJVIR-1ST DOSE ON OR AFTER FIRST BIRTHDAY OR I I I I

MEASLES I I I I MUMPS I I I RUBELLA I I I

HEPATITIS B I I I PEDIARIX (DTAPIIPVlHepB) I I !­ -­VARICELLA I I I HEPATITIS A I I I I PNEUMOCOCCAL(PCV) I 1 I I PROQUAD (M:M:R/VARICELLA) I

I I COMVAX (BepBIHIB) . I I I OTHER I I I I HGB IHCTIRESULT I I LEAD SCREENING RESULT I

PPD: COMPLETE THE BACK of this form for TUBERCULOSIS SCREENING

DATE OF EXAM PHYSIClAN'SSIGNATURE AND STAMP

Medical exam rev. 01110&

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GREENBURGH CENTRAL SCHOOL DISTRlcr NO.7 MARlA REGINA HIGH SCHOOL 475 WEST HARTSDALE AVENUE 500 WEST HARTSDALE AVENUE HARTSDALE, NEW YORK 10530 HARTSDALE, NY 10530

TUBERCULIN SCREENING REPORT FORM

TO BE COMPLETED PRIOR TO ENTRANCE TO SCHOOL

D,O,B, NAME OF CHILD

SCHOOL GRADE

EITHER A OR B MUST BE COMPLETED BY PHYSICIAN

A. PPDlMantoux:

1. DatePlaced:_.,.- Date Read: Results in mm _

2. If PPD is Positive: CXR: Date of exam: / / Result:

Treatment:

B. Tuberculin screening not indicated (see below) (MD must initial)

Universal tuberculin screening is not recommended in the U.S. and other low-incidence countries due to the high rate of false positives. Tuberculin screening is however, indicated for children with the following risk factors for TB:

1_, Immj'OT::ltion frnm ~ rn1 ,ntrv "'j'th <l L;O'h ;T"ICI' .-1 e"'''C> "'f TD (m~~' "o··-t-:es ~.(: 1\ ~;~ A frl' -a CenLra'___ .. :>__ ......... ...... ....... _ .......... """"' ........... ) .. ~ ....u ..... 1~ .. .=.&. ..... "'. '\..&. .L.LVV V J. J.J \ 1 V,,:,\.. \..0 UU 1 J U! rJ,.::Ha., n...l. lv, l 1

and South America), 2, Travel to a high incidence country for more than one month (where housing was with family

members, not hotels). 3, Household contact with parents or others who emigrated from a country with a high incidence of

TB and tuberculin status unknown (consider testing at ages 1, 5, and 12), 4. Exposure to individuals within the past 5 years who are HIV-infected, homeless, residents of

nursing homes, institutionalized, user of illicit drugs, incarcerated (test all groups every 2-3 years).

5 HIV infection (test yearly), diabetes mellitus, chronic renal failure, malnutrition, immunosuppressive therapy.

Medical exam. rev, 011108

' • .&.rU.~ .L'-1O"U".Ll,n ~.l\.Jn ~\..-nVVL

SOO West Hartsdale Avenue Hartsdale. New Yark 10530

SPORT PHYSICAL FORM

GJ)-... fP~,

Sport physicals may be obtained from your O'A'TI physician This is the ONLY sport ohvsical form that will be accepted by the school. Individual notes or other physical examination forms will not be accepted.

lfthe physical is done by own physician., it must both be signed by him and stamped with his office stamp. The date of the actual physical must be included. Only ph~lsical done within the last 30 davs before the start of a sport season will be accepted. Sport physicals are valid for 12 consecutive months unless voided by illness of five or more consecutive days or serious injury. Before a student may resume a sport or start a new season a letter of clearance must be received from the attending phvsician and can be reviewed b\' the school phvsician

Whether the physical is done privately or by the school physician the medical history below must be filled out and signed. The school physician has the fmal authority to determine the physical capability of a srudent to participate in a sport.

MEDCIAL mSTORY

Medical history mustbe signed by the parent before the student may be cleared for sports.

NlVv1Eo AGE __GRADE__ SPORT _

Write in YES or NO neA'! to the following questions Explain all YES answers in area provided below.

___ Any known medical condition __ Been unconscious or lost memory Allergies or Hay fever ___ Became dizzy or fainted following exercise

___ Reaction to Bee stings Convulsions or seizures ___" Takes medication daily __Poor or single vision ___ Hospitalized in the past year __ Wears glasses or contaet5 ___ Emergency room ~are past year __ Hearing impairment or hearing aids

Operations __ High blood pressure --- History of diabetes == Heart Murmurs or Conditions

lc".sthma or respiratory conditions __ Had chest pain during or after exercise ___ Asthma requiring inhalers or rreannent __ Orthodontic applications or ~pped teeth ___ Bleeding tendency or anemia ___ Broken bones or joint injury Females Onlv ___ Serious strains or spLains ___ One kidney or testicle At what age did your period start?-----

Urinarv tract infections--­ . ___ Serious head injury or concussion

Does your period come regularly? Date of your last period

_ _

***Date of last tetanus toxoid _

Explanation _

Name or Physician or Clinic _

I hereby aclmowledge that I Imow of no physical reason why my child should not participate in interscholastic

sports.

Date: _ Signature (Parent/Guardian) _

"/ARNING: SERIOUS INJURY CAN AND MAY OCCUR IN ANY ATHLETIC COl\TTEST

SPORTS PHYSICAL REV.12/ 08

---

INTER-SCHOLASTIC SPORT PHYSIC.t\L

Name Age Grade Sport _

HT. WT.-------- PULSE B.P. 1

ProteinUrine Glucose------------ -------------­An~' known aUergies Presently wears glasses / contacts__Hearing aid__

Any know serious injury or medical conditioD - _

Skin _ Lungs _ liE.E.N.T. _ Hernia _ Heart, _ Ortbopedic, _

Scoliosis, _Lymph Nodes _--­Thyroid Tanner-12345

Other/comments: _

I, the undersigned., have reviewed the medical history and examined the above named student and certify there is no known medical evidence available to me which would prelude his/ her participation in:

Contact I Collision (ALL SPORTS) r. "'Limited Contact! Impact - Only

"*Strenuous Endurance non contact Only r. "'Non Strenuous - non contact Onlv

KEY Contact/Collision Limited Contact Strenuous Endurance non Non Strenuous (ALL SPORTS) Impact - Only contact Only non contact Only

Hockey (Field) Basketball Cross COtUltry Golf Football Baseball Track and Field Bowling

Soccer Softball Swimming Wrestling Diving Tennis

Gymnastics Skiing Volleyball Cheerleading

Circle one: Cleared for sports Disqualified

**Further input from student's physician required _

List Restrictiol1S _

Date _ MD Signature _ Office Stamp:

Referral Date: Parents notified _

Response (attach copy) Date: _

SPORTS PHYSIC.A.L, REV.l21 08

GREENBURGH CENTRAL SCHOOL DISTRICT NO.7 MARlA REGINA HIGH SCHOOL 475 West Hartsdale Avenue 500 West Hartsdale Avenue Hartsdale, New York 10530 Hartsdale, New York 10530

SELF MEDICATION AUTHORIZATION FORM

IUrI'IJRN ONI~Y IF S'I'IJnEN'I' NI~I~nS '1'0 'fAKE MEnICl\'fION IN SCBOOI~

I~OR EX1UII)LI~: III)), I~PI-PEN, INSIJLIN ANn/OR INSIJUN PIJIIP, GLIJCAGON

Student's Name: Grade:-- Date: _

Has been instructed in the proper use ofthe following medication procedures:

I, (Physician's signature and stamp) Date: _

and (Parent or Guardian's signature) _

Telephone _ Home work cell

request that (Child's Name) _

be permitted to carry the medication on her person. She has been instructed in and understands

the purpose and appropriate method and frequency of use.

Please return to the School Nurse This form has to be completed at the beginning of every school year

and/or at the start of fall sports

--------------------------

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GREENBURGH CENTRAL SCHOOL DISTRICT NO.7 MARlA REGINA HIGH SCHOOL 475 WEST HARTSDALE AVENUE 500 WEST HARTSDALE AVENUE HARTSDALE, NEW YORK 10530 HARTSDALE. NEW YORK 10530

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION IN SCHOOL

UI~'I'UUN ONI..Y Il~ S'l'U))I~N'I' NI~I~))S '1'0 rl'l\KI~ ~1I~1)J(~l\'I'ION IN S(~BOOI ..

I~OU 1~X1\~Il)U~: rI'YI..l~NOI/~IO'l'lUN, IU~Nl\))UYI .., 1\N'I'I1nO'l'I(~S

1. To be comyfeteaby the yarent or guardian:

I request that my child grade: receive the medication as prescribed below by your licensed health care provider The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the school nurse will administer the medication.

Parent or Guardian's signature: Date: _

Telephone: Home: Cell/ Work: _

2. To be comyfeteaby the ficensea hearth care yrescrifJer:

I request that my patient, as listed below, receive the following medication:

Name of Student: Date of Birth _

Diagnosis: _

Name of Medication

Prescribed Dosage, Frequency and Route of Administration: _

Time to be taken during school hours: _

Duration of treatment:

Possible Side Effects and Adverse Reaction

Name of Licensed Health Care Worker, Title, Signature and Stamp:

Date

Please return to the School Nurse.

GREENBURGH CENTRAL SCHOOL DISTRICT NO.7 415 WEST HARTSDALE AVENUE HARTSDALE, NEW YORK 10530

DENTAL HEALTH FORM "

To: All parents/Guardians

From: GCSD7 School Nurses "

People can keep their teeth tbrougbo~ life ifthey do their part and allow the dentist to do hisIber part. Most dental disease is preventable. Starting at age 3, regular visits to the dentist are essential. During a dental visit the dentist should:

1. Examine teeth and gums. 2. Prophylaxis (clean/fluoride). 3. Check for cavities and fill as needed. 4. Prevent major dental problems. 5. Provide dental health instructions.

What can parents/guardian do?

1. Provide a well balanced diet for the family. 2. Help children limit sugary snacks-<>ffer healthy snacks. 3, Encourage children to brush promptly and properly after eating-using fluoride. toothpaste. 4. Take child to the dentist yearly, more often as needed.

Ifyour child has not had a dental exam with the past year, please call today and schedule an appointment. Ask your dentist to fill out the bottom of this form and retmn it to the school nurse. Thank you!

SCHOOL: TEACHER: GRADE: _

Student's Name _

The above student has had a dental examination and the necessary work is:

Completed _ In process _

Dentist signature Date

Dental Fonn, rev 8/04

GREENBURGH CENTRAL SCHOOL DISTRICT NO. 7

PLEASE NOTE: THIS FORM MUST BE RETURNED TO THE SCHOOL NURSE IN THE BUILDING YOUR CHILD ATTENDS CLASS. THANK YOU.

__...~ CHECK AND SIGN A, B, OR C and D.

A. _ My child has no known allergies.

Signed: _ Date: _

B. _ My child has a known allergy

to . Reactions generally are not severe.

Signed: _ Date: _

Co _ My child has a known severe allergy to

______________________. In the event of a contact, I

give my permission for the school nurse, or her designee to follow the protocol written by

Dr. _

(Your child physician's name) (Address)

(Phone number)

This may include the administration of medications and transport by emergency care unit to the nearest emergency room. I will be notified immediately.

Signed: _ Date: _

========================================================================================== D. I give permission for the school to share this information, on an as needed basis, to the teaching staff, food service. administrator, and other faculty.

Signed: _ Date: --------­

Allergy Letter, rev 4/04

DATE OF BIRTHSTUDENT'S LAST NAME STUDENT'S FIRST NAMEEMERGENCY INFORMATION RECORD (pLEASE PRINT) H9ME STREET ADDRESS, CITY, STATE ZIP CODE GRADE

PARENT I GUARDIAN'S NAME PARENT I GUARDIAN'S NAME HOME PHONE

MOTHER'S BUSINESS PHONE I CELL PHONE FATHER'S BUSINESS PHONE I CELL PHONE

IN CASE OF EMERGENCY AND PARENT IS NOT AVAILABLE CONTACT CELL' _

HOME. _

(NAME) (ADDRESS) WORK::

CELL. _

HOME: _

2. ---;==~------------------""';'7===~------------------:W~O=RK~·: (NAME) (ADDRESS)

__=;;::;:';;": (PHONE)

_

STUDENT'S PHYSICIAN PHONE STUDENTS DENTIST PHONE

HOSPITAL WHERE STUDENT SHOULD BE TAKEN IF PARENT OR PHYSICIAN IS UNAVAILABLE (LOCAL)

ALLERGIES AND OTHER MEDICAL CONDITIONS: (PLEASE EXPLAIN CHECKED ITEMS BELOW OR, IF NECESSARY, USE OTHER SIDE OF CARD) ..I ALLERGIES ..I ASTHMA CJ DIABETES CJ EPILEPSY U HEART PROBLEMS ..I RECURRING ILLNESS U OTHER

1D case of accident or serious illness, I request lhe school to conlact me. If lbe school is unable to reacb me, 1hereby authorize the school 10 call the pbysician indicated above and to foUow hisJ her instructions. If it is impossible to contact this pbysician, the school may lake wbalever arrangements seem necessary. 1 also give permission for medical alert information 10 be shared with the Greeoburgh Cafeteria Staff and Transpomtion Departmenl.

SIGNATURE OF PARENT I GUARDIAN DATE _