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LHSAA MEDICAL HISTORY EVALUATION IMPORTANT This form must be completed annuarry. kept on file with the school, & is subject to inspection by the Rules Compliance Team

Na:nc

Sporl(s)r_

IIomc Addrcss:

Parenl / Guardian:

School

Grade:_Datc

Sex: M / F Date of Birth:

Agc:_CellPhonc

City

Slate:_ Zip Code

Homc Phonc

Employer

Work Phone

FAMILY MEOICAL HISTORY: Has any member of your family under age 50 had lhese conditions?

No Condilion

D E Heart AtlacUDisease tr D Stroke B tr Diabetes

Whom

Yes No Condition

E tr Sudden Dealh tr tr High Blood Pressure tr tr Sickle Cell TraivAnemia

Condition

Dtr Arthritis tro Kidney Disease trtr Epilepsy

ATHLETE'S ORTHOPAEDIC HISTORY Has the athlele had any of the following injuries?

Yes No Condition

Date

tr tr Head lnjury / Concussion

Dtr

Otr

Elbow L / R

HipL/R

tr D Lou/erLeg L/R

D tr FootL/R

D O Chest

Yes No Condition

Date

D D Neck lnjury / Stinger

tr D Arm/Wrist/HandL/R

O tr Thigh L / R

tr tr Chronic Shin Splints

O D Severe lvll$cle Strain

_ Previous Surgeries'

Condition

trtr Shoulder L/ R oo Back otr KneeL/R tro Ankle L / R otr Pinched Nerve

Dale

ATHLETE MEOICAL HISTORY: Has lhe athlele had any oflhese condrtiors?

No Condition

tr tr Heart Murmur / Chest Pain / Tightness

No Condition

tr tr Asthma / Prescribed lnhaler

No Condition

tr tr Menslrual inegularities: Lasl Cycle:_

o tr Seizures

tr D Shortness of breath / Coughing

tr tr Rapid !'ight loss / gain

tr tr Kidney Disease

tr tr Hemia

D o Take supplementyvitamins

tr tr lrregular Heartbeat

o o Knocked out / Concussion

tr tr Heat related problems

o o Single Testicle tr o High Blood Pressure

tr tr Hearl Disease tr D Diabetes

tr tr Recenl I\rononucleosi o o Enlarged Spleen

o tr Dizzy / Fainting

tr tr Liver Disease

D tr Sickle Cell TraiuAnemia

tr o Organ Loss (kidney, spleen, elc)

oD

ttrr

Surgery Medications

o o Tuberculosis tr tr Prescribed EPI PEN

tr tr Overnight in hospital

D D Allergies (Food, Drugs)_

ListDateslor:LastTeianusShot:-Measleslmmunization:lvleningilisVaccine

PARENTS' WAVER FORM

To lhe best of our knowledge, we have given true & accurate informalion & hereby granl permission for the physical screening evaluation. We understand lhe

evaluation involves a limited examinalion and the screening is nol intended to nor will rl prevent injury or sudden dealh. We furlher understand lhat if the

exam ination is provided without expectation of payment, lhere shall be no cause of aclion pursuanl lo Louisiana R.S. 9:2798 againsl the team volunteer health-

care provider and/or employer under Louisiana law.

This waiver, executed on the date below by the undersigned medical doctor, osteopathic doctor, nurse practitioner or physician's assistant and parent of the

student alhlele named above, is done so in compliance with Louisiana law with the full understanding thal there shall be no cause of actjon for any loss or damage

caused by any acl or omission related to the heallh care services if rendered voluntarlly and without expectation of payment herein unless such loss or damage was caused by gross negligence. Additionally,

'1. lf, in the judgment of a school representative, the named student-athlete needs care or keatment as a resull of an injury

orsickness, ldoherebyrequesl,consentandaulhorizeforsuchcareasmaybedeemednecessary......................-...........................-.Yes No

2. I understand that if the medical stalus of my child changes in any significant manner after his/her physical examination,

school.. 3. I give my permission for the athletic kainer to release anformation concerning my child's injuries to the head coach/athletic drrector/pnncrpal of his/her

4.

By my

bylhe

signalure belou I am agreeing to allow my child's

LHSAAorrts Represenlalrve(s)....

medical

history/exam

form

and

all

eligibility

forms

lo

be

reviewed

....

...... . .. .. yes

No

.. ......Yes No

Date Signed by Parent

Signature of Parent

Typed or Printed Name of Parent

ll. COMPLETEO ANNUALLY BY MEDICAL DOCTOR (MD), oSTEOPATHIC DR. (Do), NURSE PRACTITIONER (APRN) or PHYSICIAN'S ASSISTANT (PA)

Heighl _

Weight

Blood Pressure

Pulse_

GENERAL IMEDICAL EXAM

N orm

Abnl

ENT

tr

tr

Lungs

tr

o

Hearl Abdomen

D

tr

tr

o

Skin Hernia

o

tr

tr

tr

(if Needed)

COI\4 [/ENTS

OPTIONAL EXAMS

VlSlONi

L:

R:

Corrected

DENTAL:

1 2 3 4 5 6 7 8 91011 1213141516

31 30 29 28 27 26 25 24 23 22 21 20 t9 18 17

From lhis limited screening I see no reason why this student cannot participate in athletics

( I Student is cleared I I Cleared after furlhe/ evaluation and treatment for

[ ] Not cleared for: _contact _non-contect

ORTHOPAEDIC EXAM

Norm Abnl

l. Spine / Neck

Cervical

tr

D

Thoracic

o

o

Lumbar

o

tr

ll. Upper Extremity

Shoulder

tr

o

Elbow

tr

tr

tr

tr

Hand / Fingers

I ll. Lower Extremity

Hip

tr

tr

Knee

o

o

Ankle

o

tr

Printed Name of lVlD, DO, APRN or PA

Siqnature oI MD, DO. APRN o. PA

Date of Medical Examination

This physical expires 13 months from the date it was signcd and dated by the MD, DO, APRN or pA.

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