Name_________________________________ Sport________________________
Date of birth__________________ Grade___________
THIS FORM MUST BE COMPLETED AND RETURNED TO THE HEALTH OFFICE BEFORE A STUDENT CAN RECEIVE CLEARANCE FOR SPORTS, AND BEFORE A PHYSICAL EXAM WILL BE PERFORMED BY THE SCHOOL HEALTH CARE PROVIDER.
Does your child have a history of any of the following?
Yes No Yes No
Asthma ___ ___ Elevated Blood Pressure ___ ___
Bee Sting Allergy ___ ___ Headaches ___ ___
Allergies ___ ___ Head Injury/Concussion ___ ___
Anemia ___ ___ Heart Problem/Murmu
Arthritis ___ ___ Chest Pain ___ ___
Bladder/Kidney ___ ___ Nosebleeds/frequent or severe ___ ___
Problem or Injury Ankle Injury ___ ___
Convulsions/Seizures ___ ___ Back Pain/Injury ___ ___
Fainting Spells ___ ___ Fracture/Dislocation-Bones
Diabetes ___ ___ or joints ___ ___
Ear Problems/Hearing Los ___ ___ Knee pain/Injury ___ ___
Eye Problems/Vision Los ___ ___ Neck Injury ___ ___
Injury to the Spleen ___ ___ Nose Fracture ___ ___
Joint Sprain/Ligament Tea ___ ___ Rheumatic Fever ___ ___
Muscle Pull Stomach Ulcer ___ ___
Single Kidney ___ ___ Single Testicle ___ ___
Severe allergy requiring the use of an Epipen? ___ ___
History of heart murmur, irregular beat, or enlarged heart? ___ ___
Prior occurrence of chest pain/ discomfort or fainting with exercise? ___ ___
Excessive and unexplained shortness of breath or fatigue with exercise? ___ ___
Has your child ever been in Adaptive Physical Education, or limited from
Competitive sports? ___ ___
Does your child wear glasses or contact lenses? ___ ___
Does your child have an orthodontic appliance or capped teeth? ___ ___
IN THE PAST 12 MONTHS HAS YOUR CHILD:
Had any injuries requiring medical attention? ___ ___
Yes No
Had any illness lasting more than 5 days? ___ ___
Been unconscious or lost memory due to a blow on the head? ___ ___
Been treated in a hospital or emergency room? ___ ___
Had infectious mononucleosis? ___ ___
Taken any medications (including inhalers) under a physician’s care? ___ ___
Is your child taking any my medication now? ___ ___
**New York State requires pupils needing prescribed or over the counter medications during school or school related activities have parent’s and physician’s written consent on file with the School Nurse.
FAMILY HISTORY
Death from cardiac (heart) disease or sudden death before age 50? ___ ___
Significant disability for cardiovascular disease before age 50? ___ ___
**If you have answered YES to any of the above questions, please describe and give the date of illness/injury if applicable. Yes answers do not mean automatic disqualification, however, written clearance from your physician may be required to participate______________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
To my knowledge, there is no medical reason that my son/daughter cannot participate in Interscholastic Sports.
I also agree to emergency medical treatment as deemed necessary by the physician designated by school authorities.
Sports participation:
_____ Approved _____ Refer to school physician
Signed ________________________________ Date _________________
(School Health Office)
If referred to school physician:
______ Qualified ______ Disqualified
Signed______________________________ Date_______________
(School physician)