FAIRFIELD HIGH SCHOOL ATHLETICS



SPORTS PARTICIPATION MEDICAL EXAMINATION

To the Health Care Provider – Please complete and sign *Mandated Screening/Test under CT State Law

Name: _____ Date of Birth: _______________Date of Exam: _______________

|General Exam |Normal |Abnormal Findings |

|Appearance | | |

|Skin | | |

|Heent | | |

|Respiratory | | |

|Cardiovascular | | |

|Arrhythmia: | | |

|Murmur: | | |

|Abdomen | | |

|Neurological | | |

|Genitalia (hernia) | | |

|Physical Maturity (Tanner Stage) 1 2 3 4 5 |

Height:* Weight:*_______________

Blood Pressure:* Pulse: ________________

HCT/HGB:*____________

Urinalysis: Protein: Blood: Glucose:______

Visual Acuity:*________ Right Left

Corrected to Right Left

Hearing:*___________________________________

Gross Dental:*________________________________

| |

|Body Fat____________% |

|Cholesterol ___________% |

|Last Tetanus Booster Date:________ |

|Last Measles(MMR) Booster Date:________ |

|HBV 1_________2_________3___________ |

|Varicella Disease Date_______________OR |

|Varicella Immunization 1_______2________ |

Chronic Disease Assessment*

Yes No

__ __ Asthma:__mild__moderate__severe

__exercise induced__unclassified

__ __ Diabetes__Type I__Type II * TB: IN HIGH RISK GROUP ___YES ___ NO

TB TEST DATE RESULTS

__ __ Seizure Disorder ________________________________________________

__ __ Anaphylactic Reaction:__ food __ insect __ latex

__ __ Other: Please specify_______________________

Musculoskeletal Evaluation to include range of motion, strength, flexibility

| |Normal |Abnormal Findings |

|Neck | | |

|Spine | | |

|Postural* | |Min. ____Slight____Mod.____Marked____ |

|Shoulders | | |

|Arms/Hands | | |

|Hips | | |

|Thighs | | |

|Knees | | |

|Ankles | | |

|Feet | | |

Comments and Recommendations

Weight loss/gain _________________________Medications ________________________________

Strengthening ___________________________Special Equipment____________________________

Stretching ______________________________Bracing/Taping ______________________________

Conditioning (endurance) ___________________________ Comments_________________________

•I certify that on this date I have examined this student and that, on the basis of the examination requested by the school authorities and the student’s medical history as furnished to me, I have found no reason which would make it medically inadvisable for this student to compete in supervised athletic activities except those listed:

__________________________ ____________ ___________________

Signature of Physician, RN, APRN,PA Telephone Provider Print or Stamp

Sports Participation Health Record

This evaluation is to determine readiness for sports participation. This must be completed by a parent and student before being brought to the Doctor’s office.

Name:__________________________________Age:_____Sex:_____School______________

Address:______________________________Phone:__________________Grade:__________

Sports being played (1)_____________(2)________________(3)________________________

Medical History

(To be completed by student and parent/guardian)

1.Do you have any allergies?(Drugs, Food, Insect Stings, etc.)

____________yes; List______________________________________________ _____________No

2. Are you currently taking any drugs or medications including steroids or protein supplements(Daily or occasionally)

____________yes; List_______________________________________________ ______________No

3. Are you presently being treated for any condition by a physician or other health care professional?

____________yes; Explain____________________________________________ ______________No

4. Have you ever been advised by a doctor not to participate in any sport?

____________yes; Explain____________________________________________ _____________ No

5. Do you have any chronic conditions, disorders or diseases? Check those applicable or….______________ No

______Asthma ____Bleeding Disorders ____Diabetes ___Epilepsy(Seizures)

______Hepatitis(liver disease) ____Hypertension(High Blood Pressure) ____Sickle Cell Anemia ___Other_________

______Mononucleosis-Yr __ ____Kawasaki Disease ____Disability (describe)__________________

Please Check where applicable if you have or have had any of the following:

Yes No Yes No

Head injury, concussion, or been unconscious ___ ___ Eye injury or retinal detachment ___ ___

If yes, how many times_________ Blurred vision or vision in one eye only ___ ___

Headaches more than once a week ___ ___ Wear glasses or contact lenses ___ ___

Lack of feeling or numbness in any part of the body___ ___ Hearing loss or impairment in one or both ears

Heat exhaustion or heat stroke ___ ___ Tubes in ears or perforated ear drum ___ ___

Difficulty running ½ mile without stopping ___ ___ False teeth, caps or braces ___ ___

Chest pain, dizziness or passing out during exercise ___ ___ Nose bleeds for no reason ___ ___

Coughing, wheezing or gasping for breath Bruising easily or taking a long time to stop bleeding

with exercise or cold weather ___ ___ when cut ___ ___

Smoke cigarettes or chew tobacco ___ ___ Diarrhea more than once a week ___ ___

Heart problem, murmur or arrhythmia ___ ___ Black or bloody bowel movements (stools) ___ ___

Family member with a heart attack under age 50 ___ ___ Kidney disease or dark, brown or bloody urine ___ ___

Loss or gain of more than 10 lbs. in last year ___ ___ Less than two kidneys or in males, two testicles ___ ___

Special diet for medical reasons ___ ___ Lump(s) in arm pit or groin ___ ___

For female participants Rash or skin problem ___ ___

Absent or irregular monthly periods ___ ___ Neck, spine or low back injury or pain ___ ___

Disabling cramps with your menstrual periods ___ ___

Have you ever been hospitalized for medical or surgical reasons? __ __

If yes, provide the following information:

Reason Year Hospital

_________________________________ ___________ ________________________________________________________

_________________________________ ___________ ________________________________________________________

Please carefully list below any injury (nerve, muscle, bone or joint) that you have had which did not allow you to participate in regular activity for a week or more.

Injured Area Year Side Type Resolved

(knee, Hamstring, Neck, Shin, etc.) _______ (R/L) (Fracture, Sprain, Swelling, Pinched Nerve, etc. Yes No

__________________________ ______ ____ __________________________________ _____ _____

__________________________ ______ ____ __________________________________ _____ _____

Student and Parent or Guardian:

We hearby state that we have reviewed this medical history and found the information supplied above to be correct to the best of our knowledge.

_________________________________ ______ ___________________________ _____________

Student Signature Date Parent/Guardian Signature Date

SHM Vol. I Sec. 6 7/06

Physical Exam Requirements for Interscholastic Sports Participation

To participate in interscholastic sports at the Varsity, JV or Freshman level, students are required to have a physical exam on record in the nurse's office by their health care provider (physician, physician's assistant, APRN or RN.)

This exam must have been done within thirteen (13) months prior to the start of tryouts, practices, or play in the particular sport in which the student plans to participate. If this physical expires during the sport season, a new physical must be submitted to the nurse in order for the student to continue participating in that sport.

This physical must be on record PRIOR to try-outs; there are no exceptions.

All health assessments must be complete. Both sides must be completed (one side by parent and one side by the health care provider) and every item marked with an asterisk * must be filled in. Per our policy, any health assessment that has missing mandated information will be considered incomplete and will be returned to you for completion. This will delay a student’s participation in sport as students will not be allowed to try out, practice or play until the form is completed.

Points to Remember:

Due to the large number of students who participate in sports, it is often difficult to get an appointment with your health care provider on a last minute basis. Parents whose children plan to participate in a sport are urged to make an appointment with their health care provider well in advance of the intended sports season. We recommend you keep a copy of your child’s physical for your records at home.

Physicals are to be submitted to the nurse’s office, not the coach. Coaches can not clear a student medically to participate in sports. Please hand in your physical as soon as it is completed. Do not wait for the sports season to begin.

Deadline for handing in physicals for the fall sport season is:

Friday, August 13, 2010 for Football Friday, August 20, 2010 for all other sports

The Health Office will be glad to help you clarify any matter relating to sports physicals. Please call 255-7204 for assistance.

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