MISSISSIPPI ATHLETIC PARTICIPATION FORM

ATHLETIC HEALTH HISTORY

Name:

Date:

School:

Grade:

Sport(s):

Sex:

Male Female

Date of Birth:

S.S.N.:

Age:

Address:

Home Phone:

Family Physician:

Work Phone:

Parent / Guardian Name:

Work Phone:

FAMILY MEDICAL HISTORY

Has any member of your family under age 50 had these conditions?

Heart Attack:

Yes No

Whom:

Sudden Death:

Yes No

Whom:

Stroke:

Yes No

Whom:

Heart Disease / High Pressure:

Yes No

Whom:

Diabetes:

Yes No

Whom:

Sickle Cell Anemia:

Yes No

Whom:

Arthritis:

Yes No

Whom:

Epilepsy:

Yes No

Whom:

Kidney Disease:

Yes No

Whom:

ATHLETE'S ORTHOPAEDIC HISTORY

Has the athlete had any of the following injuries?

Head Injury / Concussion:

Yes No

Date:

Shoulder (L):

Yes No

Date:

Shoulder (R):

Yes No

Date:

Elbow (L):

Yes No

Date:

Elbow (R):

Yes No

Date:

Hip:

Yes No

Date:

Knee (L):

Yes No

Date:

Knee (R):

Yes No

Date:

Chronic Shin Splints:

Yes No

Date:

Foot (L):

Yes No

Date:

Foot (R):

Yes No

Date:

Pinched Nerve:

Yes No

Date:

Neck Injury / Stinger:

Yes No

Date:

Arm (L):

Yes No

Date:

Arm (R):

Yes No

Date:

Wrist (L):

Yes No

Date:

Wrist (R):

Yes No

Date:

Hand (L):

Yes No

Date:

Hand (R):

Yes No

Date:

Back:

Yes No

Date:

Thigh (L):

Yes No

Date:

Thigh (R):

Yes No

Date:

Lower Leg (L):

Yes No

Date:

Lower Leg (R):

Yes No

Date:

Ankle (L)

Yes No

Date:

Ankle (R)

Yes No

Date:

Severe Muscle Strain:

Yes No

Date:

Chest

Yes No

Date:

Previous Surgeries:

ATHLETE'S MEDICAL HISTORY

Has the athlete had any of these conditions?

Heart Murmur:

Yes No

Organ Loss:

Yes No

Overnight in hospital:

Yes No

Seizures:

Yes No

Shortness of breath / coughing during exercise:

Yes No

Hernia:

Yes No

Kidney Disease:

Yes No

Knocked out:

Yes No

Rapid weight loss / gain:

Yes No

Irregular Pulse:

Yes No

Heart Disease:

Yes No

Take supplements / vitamins:

Yes No

Single Testicle:

Yes No

Diabetes:

Yes No

Heat related problems:

Yes No

High Blood Pressure:

Yes No

Liver Disease:

Yes No

Menstrual irregularities:

Yes No

Dizzy / Fainting:

Yes No

Tuberculosis:

Yes No

Recent Mononucleosis / Enlarged Spleen:

Yes No

Surgery - What Type?

Yes No

Specify:

Allergies (Food, Drugs):

Yes No

Specify:

Date of last Tetanus Immunization:

To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals providing services may be immune from liability under Mississippi law.

WAIVER FORM

Date:

Physician's Name:

Patient's Name:

This waiver, executed by given date above by physician and patient, is executed in compliance with Mississippi law, with the full understanding that if a physician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.

Patient/Parent/Guardian Signature:

Patient's Parent or Guardian (If Patient is 17 or younger)

Information below to be filled out by physician only

Height:

Weight:

Blood Pressure:

Pulse:

Orthopaedic Exam

I. Spine / Neck:

Normal:

Abnormal:

Cervical:

Normal:

Abnormal:

Thoracic:

Normal:

Abnormal:

Lumbar:

Normal:

Abnormal:

II. Upper Extremity:

Normal:

Abnormal:

Shoulder:

Normal:

Abnormal:

Elbow:

Normal:

Abnormal:

Wrist:

Normal:

Abnormal:

Hand / Fingers:

Normal:

Abnormal:

III. Lower Extremity:

Normal:

Abnormal:

Hip:

Normal:

Abnormal:

Knee:

Normal:

Abnormal:

Ankle:

Normal:

Abnormal:

Feet:

Normal:

Abnormal:

Other Comments:

General Medical Exam

ENT:

Normal:

Abnormal:

Heart:

Normal:

Abnormal:

Skin:

Normal:

Abnormal:

Lungs:

Normal:

Abnormal:

Abdomen:

Normal:

Abnormal:

Hernia (if Needed):

Normal:

Abnormal:

General Health Comments:

FLEXIBILITY

Neck:

LEFT:

RIGHT:

Hips:

LEFT:

RIGHT:

Hams:

LEFT:

RIGHT:

Back Ext / Flex:

LEFT:

RIGHT:

Shoulder:

LEFT:

RIGHT:

Quads:

LEFT:

RIGHT:

Heelcords:

LEFT:

RIGHT:

Comments:

OPTIONAL EXAMS

Comments:

VISION

Left:

Right:

Comments:

From this limited screening I see no reason why this student cannot participate in athletics

Student needs further evaluation as described

Name of Physician:

Signature of Physician:

PHYSICIAN - WHITE SCHOOL - CANARY PARENT/GUARDIAN - PINK

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