Medical History Form

To be completed by parent or guardian or 18-year-old.

Must be signed below by parent or guardian or 18-year-old.

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

Last Name

First Name

Grade

Date of Birth

Student's Address

City

State

Zip

Name of Father or Guardian

Work Phone

Name of Mother or Guardian

Work Phone

Family Doctor

Office Phone

Student's Home Phone

General Question

Has a Doctor ever denied or restricted your participation in Sports for any reason?

Yes No

Do you have any ongoing medical conditions?

Yes No

If so, please Identify by Circling:

Asthma

Anemia

Diabetes

Infections

Other

Have you ever spent the night in the hospital?

Yes No

Have you ever had surgery?

Yes No

Your Family's Heart Health Questions

Does anyone in your family have arrhythmogenic right ventricular cardiomyopathy, long QT syndrome?

Yes No

Has any family member or relative died of heart Problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome) ?

Yes No

Medical Questions

Do you have any concerns that you would like to discuss with a doctor?

Yes No

Were you born without or are you missing an organ? Identify by circling: A kidney An eye Your spleen A testicle (males)

Yes No

Any other organ?

Have you ever had an eating disorder?

Yes No

Do you worry about your weight?

Yes No

Heart Health Questions About You

Have you ever passed out or nearly passed out DURING or after exercise?

Yes No

Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?

Yes No

Do you get lightheaded or feel more short of breath than expected during exercise?

Yes No

Do you get more tired or short of breath more quickly than your friends during exercise?

Yes No

Has a doctor ever ordered a test for your heart? For example: ECG/EKG, echocardiogram

Yes No

Have you ever had an unexplained seizure or do you have a history of seizure disorder?

Yes No

Does your heart ever race or skip beats (irregular beat) during exercise?

Yes No

Has a doctor ever told you that you have high blood pressure?

Yes No

Has a doctor ever told you that you have high cholesterol?

Yes No

Has a doctor ever told you that you have Kawasaki disease?

Yes No

Has a doctor ever told you that you have other heart problems?

Yes No

Has a doctor ever told you that you have a heart infection?

Yes No

Has a doctor ever told you that you have a heart murmur?

Yes No

Bone And Joint Questions

Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or a game?

Yes No

Have you ever had any broken or fractured bones or dislocated joints?

Yes No

Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace or cast or crutches?

Yes No

Have you ever been told that you have neck instability or atlantoaxial instability (Down syndrome or dwarfism)?

Yes No

Have you ever had an x-ray for neck instability or atlantoaxial instability (Down syndrome or dwarfism)?

Yes No

Do you regularly use a brace, orthotics, or other assistive device?

Yes No

Do any of your joints become painful, swollen, feel warm or look red?

Yes No

Do you have any history of juvenile arthritis or connective tissue disease?

Yes No

Have you ever had a stress fracture?

Yes No

Have you a bone, muscle, or joint injury bothering you?

Yes No

Your Family's Heart Health Questions

Does anyone in your family have a heart problem, Pacemaker, or implanted defibrillator?

Yes No

Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, Brugada syndrome?

Yes No

Anyone in your family had unexplained fainting?

Yes No

Anyone in your family had unexplained seizures?

Yes No

Anyone in your family had unexplained near drowning?

Yes No

Immunization History

Are you missing any recommended vaccines (Tdap, Flu, MCV4, HPV, Varicella, MMR)

Yes No

Medical Questions

Have you ever become ill while exercising in the heat?

Yes No

Do you cough, wheeze, or have difficulty breathing during or after exercise?

Yes No

Do you have headaches or get frequent muscle cramps When exercising?

Yes No

Do you have pain, a painful bulge or hernia in the groin?

Yes No

Is there any one in your family who has asthma?

Yes No

Have you ever used an inhaler or taken asthma medicine?

Yes No

Females Only

Have you ever had a menstrual period?

Yes No

How old were you when you had your first menstrual period?

Yes No

How many periods have you had in the last twelve (12) months?

Yes No

Insurance Statement And Certification

Our Son/Daughter will comply with the specific insurance regulations of the school district and the Medical History questions are as complete and correct
as possible.

Family Insurance Co:

Contract #:

Signatures of Student:

& Parent/Guardian or 18 Year Old:

EMERGENCY INFORMATION – To Be Completed by Parent or Guardian or 18 Year Old

Student's Name

Grade

In Emergency Contact

Phone

Cell #

Phone

Cell #

Family Doctor

Phone

Allergies

Drug Reactions

Current Medications

PHYSICAL EXAM & CLEARANCE & CONSENT FORMS

To be completed by parent or guardian or 18-year-old.

Must be signed in two places on this page by parent or guardian or 18-year-old.

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

Student's Complete Legal Name

Last Name

First Name

Student's Date of Birth

Place Of Birth

City

State

Zip

Circle Grade

School

Physical Examination & Medical Clearance

Height

Weight

BP:

Pulse

Vision R 20/

L20 /

Medical

Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Normal

Abnormal Findings

Eyes/Ears/Nose/Throat: Pupils Equal Hearing

Normal

Abnormal Findings

Lymph Nodes

Normal

Abnormal Findings

Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)

Normal

Abnormal Findings

Pulses: Simultaneous femoral and radial pulses

Normal

Abnormal Findings

Lungs

Normal

Abnormal Findings

Abdomen

Normal

Abnormal Findings

Skin

Normal

Abnormal Findings

Genitourinary (Males Only)

Normal

Abnormal Findings

HSV,

Normal

Abnormal Findings

lesions suggestive of MRSA, tinea corporis

Normal

Abnormal Findings

Musculoskeletal

Neck

Normal

Abnormal Findings

Back

Normal

Abnormal Findings

Shoulder / Arm

Normal

Abnormal Findings

Elbow / Forearm

Normal

Abnormal Findings

Wrist / Hand / Fingers

Normal

Abnormal Findings

Hip / Thigh

Normal

Abnormal Findings

Knee

Normal

Abnormal Findings

Leg / Ankle

Normal

Abnormal Findings

Foot / Toes

Normal

Abnormal Findings

Foot / Toes

Normal

Abnormal Findings

Functional: Duck Walk

Normal

Abnormal Findings

RECOMMENDATIONS

I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities NOT crossed out below

BASEBALL - BASKETBALL - BOWLING - COMPETITIVE CHEER - CROSS COUNTRY - FOOTBALL - GOLF - GYMNASTICS ICE HOCKEY - LACROSSE - SKIING - SOCCER - SOFTBALL - SWIMMING - TENNIS - TRACK & FIELD - VOLLEYBALL - WRESTLING

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Examination

Printed Name of Examiner

Date

STUDENT PARTICIPATION & PARENT OR GUARDIAN OR 18 YEAR OLD CONSENT

This application to participate in athletics is voluntary on my part and the information submitted is truthful to the best of my knowledge. I have never received money or negotiable certificate for merchandise in any amount, nor any emblematic award or merchandise worth more than twenty-five dollars ($25.00) for participating in athletic events, nor have I ever competed under an assumed name. After I have represented my school in any sport, I will not compete in any outside athletic contest in this sport until after my school season has been completed. I understand that I am expected to adhere firmly to all established athletic policies of my school district and the Michigan High School Athletic Association, such as those previously mentioned above as examples but which do not present all the policies to which I am subject.

I hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the MHSAA of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for interscholastic athletics; and I understand the possibility that serious injury may result from participating in athletic activities. He/She has my permission to accompany the team as a member on its out-of-town trips.

I further understand that my son or daughter will be expected to adhere firmly to all established athletic policies of the school district and the Michigan High School Athletic
Association.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of STUDENT

Date

Signature of PARENT or GUARDIAN or 18 YEAR-OLD

Date

MEDICAL TREATMENT CONSENT – To Be Completed By Parent or Guardian or 18-Year-Old

, an 18 year-old, or the parent or guardian of

recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent or Guardian or 18 year Old

Date

Your information will be encrypted.