Preparticipation Physical Evaluation - Medical History
This Medical History Form must be completed annually by parent (guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
In case of emergency, contact:
Explain "Yes" answers in the box below**.
How severe was each one? (explain below)
An individual answering in the affirmative to any question relating to possible cardiovascular health issue as identified on the form, should be restricted from further participation until
the individual is examined and checked by a physician, physician assistant, chiropractor, or nurse practitioner.
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League or the school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.
If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities or such illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL
Any yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific questions on the student's MEDICAL HISTORY FORM above. *Local district
policy may require an annual physical exam.
*station-based examination only
The following information must be filled in and signed by either a physician, a physician assistant licensed by a State Board of Physician Assistant Examiners, a registered nurse recognized as an advanced practice nurse by the Board of Nurse Examiners, or a doctor of chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.
Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.
Your message will be encrypted.
Your browser does not support capabilities required for electronic signatures.