Sports Physical Consent for Parents

Pre-participation physical exams cannot predict or guarantee that your child will be risk free while participating in a sport. As you might expect, there is a greater chance of injury in contact and collision sports. Additionally, routine sport physicals do not reveal some cardiac anomalies. Cardiac conditions may exist despite normal screening and examination findings. Participating in a sport may cause symptoms of undiagnosed conditions to occur and may even cause a serious health problem, including sudden death.

I understand that there are potential dangers of sports participation including injury cardiac complications and other health problems that are previously undiagnosed.

I have read and understand the above statements.

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

Parent Signature:

Patient Name:

Date:

Sports Physical Questions

1. Have you ever been hospitalized overnight in the last year?

Yes No

If YES, please expalin:

2. Do you have trouble breathing or become short of breath during or after exercise?

Yes No

If YES, please expalin:

3. Have you ever passed out, been knocked out (unconscious), or had a seizure during or after exercise?

Yes No

If YES, please expalin:

4. Have you ever had chest pain or experienoed your heart skipping beats during or after exercise?

Yes No

If YES, please expalin:

5. Has any family member or relative died of heart problems or sudden death before age 50?

Yes No

If YES, please expalin:

6. Have you or a family member ever been told you have sickle cell disease or sickle oell trait?

Yes No

If YES, please expalin:

7. Have you ever broken any bones or had major joint injury?

Yes No

If YES, please expalin:

8. Are you missing any paired organs? (Are you missing an eye, ear, lung, kidney, testicle I ovary?)

Yes No

If YES, please expalin:

9. Has a physician ever denied or restricted your participation in sports?

Yes No

If YES, please expalin:

10. Do you have a chronic illness?

Yes No

If YES, please expalin:

11. Have you ever fainted, passed out or had a seizure suddenly and without warning, especially during exercise or in response to auditory triggers like door bells, alarm clocks or ringing phones?

Yes No

If YES, please expalin:

Emergency Contact:

Name:

Phone:

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

Parent / Legal Guardian Signature:

Date:

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