Ms athletic participation form - Christian Preparatory School
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MISSISSIPPI ATHLETIC PARTICIPATION FORM
ATHLETIC HEALTH HISTORY
Please Print
Name ________________________________________________________________________ Date ________________________________ School _________________________________________ Grade _________ Sport(s) _____________________________________________ Sex: M F 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?
Yes No Condition
Whom
I I Heart Attack
________________________________________________________________________
I I Sudden Death
________________________________________________________________________
I I Stroke
________________________________________________________________________
I I Heart Disease / High Pressure
________________________________________________________________________
I I Diabetes
________________________________________________________________________
I I Sickle Cell Anemia
________________________________________________________________________
I I Arthritis
________________________________________________________________________
I I Epilepsy
________________________________________________________________________
I I Kidney Disease
________________________________________________________________________
ATHLETE'S ORTHOPAEDIC HISTORY Has the athlete had any of the following injuries?
Yes No Condition
I I Head Injury / Concussion I I Shoulder L / R I I Elbow L / R I I Hip I I Knee L / R I I Chronic Shin Splints I I Foot L / R I I Pinched Nerve
Date ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
Yes No Condition
I I Neck Injury / Stinger I I Arm / Wrist / Hand L / R I I Back I I Thigh L / R I I Lower Leg L / R I I Ankle L / R I I Severe Muscle Strain I I Chest
Date ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
Previous Surgeries: __________________________________________________________________________________________________ ATHLETE'S MEDICAL HISTORY
Has the athlete had any of these conditions?
Yes No Condition
I I Organ Loss
I I Overnight in hospital
I I Heart Murmur
I I Shortness of breath / coughing
I I Hernia
I I Seizures
during exercise
I I Rapid weight loss / gain
I I Kidney Disease
I I Knocked out
I I Take supplements / vitamins
I I Irregular Pulse
I I Heart Disease
I I Heat related problems
I I Single Testicle
I I Diabetes
I I Menstrual irregularities
I I High Blood Pressure
I I Liver Disease
I I Recent Mononucleosis /
I I Dizzy / Fainting
I I Tuberculosis
Enlarged Spleen
I I Surgery - What Type? _____________________________________________________________________________________
I I Allergies (Food, Drugs) ___________________________________________________________________________________
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
This waiver, executed this ________ day of __________________, 200______, by ___F_I_L__L__IN___A_T__T__I_M__E__O__F__P__H_Y__S_I_C__A__L___, M.D.,
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.
______________________________________________________ Typed or Printed Name of Patient
_______________________________________________________ Signature of Patient
or Patient's Parent or Guardian (If Patient is 17 or younger)
Height __________________ Orthopaedic Exam
Information below to be filled out by physician only Weight __________________ Blood Pressure __________________ Pulse __________________
General Medical Exam
I. Spine / Neck Cervical Thoracic Lumbar
II. Upper Extremity Shoulder Elbow Wrist Hand / Fingers
III. Lower Extremity Hip Knee Ankle Feet
Norm Abnl _______ _______ _______ _______ _______ _______ _______ _______
_______ _______ _______ _______ _______ _______ _______ _______ _______ _______
_______ _______ _______ _______ _______ _______ _______ _______ _______ _______
ENT Heart Skin
Norm Abnl _______ _______ _______ _______ _______ _______
Lungs Abdomen Hernia (if Needed)
Norm Abnl _______ _______ _______ _______ _______ _______
General Health Comments _____________________________________________________ __________________________________________________________________________ __________________________________________________________________________
FLEXIBILITY Neck Hips Hams
LEFT RIGHT _______ _______ _______ _______ _______ _______
FLEXIBILITY Shoulder Quads Heelcords
LEFT RIGHT _______ _______ _______ _______ _______ _______
Back Ext / Flex
_______ _______
Comments _________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Other Comments ____________________________________________________________________________________________________
OPTIONAL EXAMS
DENTAL
VISION L_________ R_________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Comments: ______________________________________________
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 _______________________________________________________
Comments _________________________________________________________________________________________________________
[ ] From this limited screening I see no reason why this student cannot participate in athletics
[ [ Student needs further evaluation as described
______________________________________________________ Typed or Printed Name of Physician
___________________________________________________, M.D. Signature of Physician
PHYSICIAN - WHITE SCHOOL - CANARY PARENT/GUARDIAN - PINK
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MSMOC 62 Rev. 3/03
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