SPORTS PARTICIPATION HEALTH RECORD

This evaluation is only to determine readiness for sports participation.  It should not be used as a substitute for regular health maintenance examinations.  THIS SIDE MUST BE COMPLETED BY PARENT & STUDENT BEFORE BEING BROUGHT TO THE DOCTOR’S OFFICE.

NAME __________________________AGE ______SEX _____ SCHOOL Academy of the Holy Family

ADDRESS__________________________ PHONE _________________GRADE ______

SPORTS BEING PAYED (1) _____________(2) ________________ (3) ________________________

MEDICAL HISTORY

(To be completed by student and parent or guardian)

  1. Do you have any allergies? (Drugs, Food, Insect Stings, etc.)

___ YES; list: _________________________________________   ___NO

  1. Are you currently taking any drugs or medication including steroids or protein supplements? (daily or occasionally)

___ YES; list: _________________________________________   ___NO

  1. Are you presently being treated for any condition by a physician or other health care professional?

___ YES; list: _________________________________________   ___NO

  1. Have you ever been advised by a doctor not to participate in any sport?

___ YES; list: _________________________________________   ___NO

  1. Do you have any chronic condition, disorders or disease?  Check those applicable (or check ...      _no)

___Asthma           ___Bleeding Disorders       ___Diabetes         ___Epilepsy (Seizures) ___Hepatitis

___Hypertension (High Blood Pressure)        ___Sickle Cell Anemia ___Mononucleosis-Yr___                       

___Kawasaki’s Disease      ___Handicap (Describe) _________________Other __________________

 

Please check where applicable if you have or have had any of the following:

__Head injury, concussion, or been unconscious

    If yes, how many times _______________

__Headaches more than once a week

__Lack of feeling or numbness in any part of the body

__Heat exhaustion or heat stroke

__Difficulty running ½ mile without stopping

__Chest pain, dizziness or passing out during exercise

__Coughing, wheezing, or gasping for breath with exercise or cold weather

__Smoke cigarettes or chew tobacco

__Heart problem, murmur or arrhythmia

__Family member with a heart attack under age 50

__Loss or gain of more than 10 lbs. in last year

__Special diet for medical reasons

__Absent or irregular monthly periods

__Disabling cramps with your menstrual periods

__Eye injury or retinal detachment

__Blurred vision or vision in one eye only

__Wear glasses or contact lenses

__Hearing loss or impairment in one or both ears

__Tubes in ears or a perforated eardrum

__False teeth, caps, or braces

__Nose bleeds for no reason

__Bruising easily or taking a long time to stop bleeding when cut

__Diarrhea more than once a week

__Black or bloody bowel movements (stools)

__Kidney disease or dark, brown or bloody urine

__Less than two kidneys

__Lump(s) in arm pit or groin

__Rash or skin problem

__Neck, spine, or low back injury or pain

Have you ever been hospitalized for medical or surgical reasons?  __ YES   __ NO

If yes, provide the following information:

REASON                                                               YEAR                                     HOSPITAL

______________________________           __________                        __________________________

______________________________           __________                        __________________________

______________________________           __________                        __________________________

Please carefully list below any injury (nerve, muscle, bone or joint) that you have had which did not allow you to participate in regular activity for a week or more?

 

INJURED AREA                       YEAR          SIDE     TYPE                                     RESOLVED (yes or no)

(Knee, Hamstring, etc.)                                       (R, L)     (Fracture, Sprain, etc.)

______________________      ______          ____       ________________________        ______

______________________      ______          ____       ________________________        ______

______________________      ______          ____       ________________________        ______

______________________      ______          ____       ________________________        ______

 

STUDENT AND PARENT OR GUARDIAN:

We hereby state that we have reviewed this medical history and found the information supplied above to be correct to the best of our knowledge.

 

__________________________        ________      _______________________        ________

  (STUDENT SIGNATURE)              (DATE)        (PARENT/GUARDIAN SIG.)     (DATE)

 

 

THE FOLLOWING IS TO BE COMPLETED BY PHYSICIAN, RN, APRN, OR PA

 

SPORTS PARTICIPATION MEDICAL EXAMINATION

To the Health Care Provider- Please complete and sign                 *=Mandated Screening/Test under CT State Law

 

Name __________________________ Date of Birth: _____________________ Date of Exam: _____________

 

General Exam

Normal

Abnormal Findings

Appearance

 

 

Skin

 

 

Heent

 

 

Respiratory

 

 

Cardiovascular

Arrhythmia:

Murmur:

 

 

Abdomen

 

 

Neurological

 

 

Genitalia

(Hernia)

 

 

Physical Maturity (Tanner Stage) 1 2 3 4 5

Chronic Disease Assessment*

Yes No

__ __ Asthma: _mild _moderate _severe

          _exercise induced _unclassified

__ __Diabetes _Type I _ Type II

__ __Seizure Disorder

__ ____ __Anaphylactic Reaction:

_ food _ insect _latex

Other:  Please specify __________________

 

Height:* _________ Weight:* ___________

Blood Pressure: * ________ Pulse:* ________

HCT/HGB:* _________

Urinalysis: ___Protein: __Blood: __ Glucose: ____

Visual Acuity: * ________ Right ______Left

Hearing: * ___________________

Gross Dental:* _______________

 

Body Fat ________%

Cholesterol _________%

 

Last Tetanus Booster    Date: ________

Last Measles (MMR) Booster   Date: _______

HBV 1 ____ 2 _____ 3 _____

 

Varicella Disease Date ____________ OR

Varicella Immunization 1 _______ 2 _______

 

*TB IN HIGH RISK GROUP ___ YES  ___ NO

TB TEST    DATE    RESULTS

________    _____     ________

 

Musculoskeletal Evaluation to include range of motion, strength, flexibility

 

Normal

Abnormal Finings

Neck

 

 

Spine

 

 

Postural*

 

Min. __ Slight __ Mod. __ Marked __

Shoulders

 

 

Arms/Hands

 

 

Hips

 

 

Thighs

 

 

Knees

 

 

Ankles

 

 

Feet

 

 

 

Comments and Recommendations

 

Weight loss/gain _____________ Medications _____________________

Strengthening _______________   Special Equipment ________________

Stretching __________                     Bracing/Taping ___________________

Conditioning (endurance) _______________

Comments ______________________________________________________________________________________

 

*I certify that on this date I have examined this student and that, on the basis of the examination requested by the school authorities and the student’s medical history as furnished to me, I have found no reason which would make it medically inadvisable for this student to compete in supervised athletic activities except those listed:

____________________________               ____________________         ___________________

Signature of Physician, RN, APRN, PA        Telephone                                     Provider Print or Stamp