Pre-participation Examination

Please correct the errors described below.

To be completed by athlete or parent prior to examination.

HISTORY FORM

Explain "Yes" answers below Circle questions you don't know the answers to.

GENERAL QUESTIONS

HEART HEALTH QUESTIONS ABOUT YOU

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

MEDICAL QUESTIONS

FEMALES ONLY

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

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.

PHYSICAL EXAMINATION FORM

EXAMINATION

MEDICAL

Appearance

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

Eyes/ears/nose/ throat

  • Pupils equal
  • Hearing

Lymph nodes

Heart

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

Pulses

  • Simultaneous femoral and radial pulses

Lungs
Abdomen
Genitourinary (males only)
Skin

  • HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCULOSKELETAL

Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/Ankle
Foot/toes
Functional

  • Duck-walk, single leg hop

• Consider KG. echocardiogram. and referral to cardiology for abnormal cardiac history or exam .
• Consider GU exam if In private setting. Having third party present is recommended.
• Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion

*effective January 2003, the IHSA Board of Directors approved a recommendation, consistent with the Illinois School Code. that allows Physician's Assistants or Advanced Nurse Practitioners to sign off on physicals.

IHSA Steroid Testing Policy Consent to Random Testing

(This section for high school students only)
2012-2013 school term

As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student's high school as specified in the IHSA Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student 10 penal ties as determined by IHSA.

A complete list of the current IHSA Banned Substance Classes can be accessed at
http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes. pdf

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.

IHSA SKIN CONDITION EVALUATION AND AUTHORIZATION TO COMPETE IN HIGH SCHOOL WRESTLING

National Federation Wrestling Rules state:

"ART 3 .. If a participant is suspected by the referee or coach of having a communicable skin disease or any other condition that makes participation appear inadvisable, the coach shall provide current written documentation as defined by the NFHS or the state associations, from an appropriate heath-care professional stating that the suspected disease or condition is not communicable and that the athlete's participation would not be harmful to any opponent. This document shall be furnished at the weigh-in for the dual meet or tournament. The only exception would be if a designated, on-site meet appropriate health-care professional is present and is able to examine the wrestler either immediately prior to or immediately after the weigh-in. Covering a communicable condition shall not be considered acceptable and does not make the wrestler eligible to participate."

"ART 4 .. If a designated an-site meet appropriate health-care professional is present, he/she may overrule the diagnosis of the appropriate healthcare professional signing the medical release form for a wrestler to participate or not participate with a particular skin condition."

Once a lesion is considered non-contagious, it may be covered to allow participation .

NOTE: On the day of a meet, the following may review a wrestler's condition: M.D., D.O., P.A., APRN, and ATC's.
In the absence of one of the previously-mentioned people, the referee has the final decision concerning the wrestler's participation.

(Name of wrestler)
( example: it is about the size of a nickel, red in color, etc. )

Note to schools: Medical authorization to compete expires 14 calendar days from the date of the examination.

Health Professional assumes all responsibility for this decision.

State of Illinois Certificate of Child Health Examination

Student's Name

HEALTH HISTORY

TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

(crossed eye, drooping lids, squinting, difficulty reading)

Information may be shared with appropriate personnel for health and educational purposes.

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.

Your information will be encrypted.

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