Name:

Grade:

M/F

(PRINT LEGIBLY) Last First Middle or Nickname ( In Fall) Circle

Birthdate:

ID#:

Sport: ________Fall ________Winter ________Spring

HEALTH HISTORY TO BE COMPLETED BY PARENT OR GUARDIAN

Has your child:

↓ If you answer “YES” to any questions, please explain below↓

1.

Had a medical illness or injury that has disqualified him/her from athletic participation?

YES

2.

Ever been hospitalized or undergone any surgical operations(s)?

YES

3.

Had an ongoing chronic or serious illness (such as diabetes, kidney problems, seizures or asthma)?

YES

4.

Ever taken any supplements or vitamins to help gain/lose weight or improve athletic performance?

YES

5.

Ever passed out during/after exercise or become ill from exercising?

YES

6.

Ever tired earlier than expected during exercise or complained of extreme fatigue?

YES

7.

Ever had chest pain or unusual/irregular heartbeats during or after exercise?

YES

8.

Had any history of heart problems, heart murmur, high blood pressure or high cholesterol?

YES

9.

Had any family member or relative die before the age of 50 or die of heart-related problems?

YES

10.

Had any family history of specific heart issues? If “YES,” check all that apply:

YES

Hypertrophic Cardiomyopathy Arrhythmia Marfan’s Syndrome Long QT Syndrome

11.

Had any history of concussion, head injury, loss of memory or being unconscious?

YES

12.

Had any history of seizures, convulsions or fainting episodes?

YES

13.

Had frequent or severe headaches?

YES

14.

Ever had a “stinger,” “burner,” or pinched nerve (numbness or tingling down an extremity)?

YES

15.

Had any problems with vision that require glasses, contacts, or protective eyewear?

YES

16.

Had special protective or corrective equipment/devices that are not usually used for sports?

YES

Examples: knee brace, neck roll, foot orthotics, retainer for teeth, hearing aids?

17.

Been diagnosed with a contagious skin condition within the past month?

YES

18.

Ever broken/fractured any bones or dislocated any joints?

YES

19.

Had any recurring problems with pain or swelling in back, muscles, tendons, bones or joints?

YES

20.

Is your child currently under the care of a physician for any medical, orthopedic or emotional concerns?

YES

21.

Had any history of asthma, allergies to foods, medicines, or stinging insects?

YES

If “YES,” what medications are used? Is Epi-Pen needed? ________________________________________________________

22.

Does your child require any special health procedure(s) during the regular school day or during athletics?

YES

23.

Is your child currently taking any prescription or “over-the-counter” medications or using an inhaler or Epi-Pen?

YES

If “YES,” list all medications:

Medication:

Dose:

Frequency:

Medication:

Dose:

Frequency:

Medication:

Dose:

Frequency:

↓If you have answered “YES” to any of the above questions, please explain below↓

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Date:

Signature of Parent/Guardian:

PHYSICAL SCREENING TO BE COMPLETED BY HEALTHCARE PROVIDER

THIS IS NOT A COMPLETE PHYSICAL EXAMINATION

Normal

Normal

General:

Musculoskeletal:

Visual acuity (Distance): Right: / Left: /

Eyes, ears, nose, throat

Neck and shoulders

Corrected Uncorrected

Neck

Spine

Height:

Cardiovascular

Arms/hands

Weight:

Femoral pulses

Hips/thighs

Blood pressure:

Chest and lungs

Knees

Pulse:

Abdomen

Ankles/feet

DATE OF EXAM:

Skin

Recommendation: Full activity-No restrictions Activity with restrictions No contact sports No participation Other

Comments: ___________________________________________________________________________

____________________________________________________________________________________

Healthcare Provider Office Stamp

Examining Healthcare Provider:

Signature:

Date:

Phone:

Fax: