Physical Examination And Parental Consent Form printable pdf download

Updated July 2013

OSSAA PHYSICAL EXAMINATION AND PARENTAL CONSENT FORM

PLEASE PRINT

DATE OF EXAM____________________________

Name ________________________________________________________________ Sex _________ Age ________________ Date of Birth ___________________________________

Grade _______________ School ____________________________________________________________________________ Sport(s) _______________________________________

Address ________________________________________________________________________________________________________ Phone _________________________________

Personal physician _______________________________________________________________________________________________ Phone _________________________________

In case of emergency, contact: Name _______________________________________________________________________________________________________________________

Relationship _____________________________________________________________ Phone (H) ________________________________ (W) ________________________________

Explain “Yes” answers below. Circle questions you don’t know the answers to.

YES NO

Have you had a medical illness or injury since your last check

Have you ever had numbness or tingling in your arms, hands,

up or sports physical?

legs, or feet?

Do you have an ongoing or chronic illness?

Have you ever become ill from exercising in the heat?

Have you ever been hospitalized overnight?

Do you cough, wheeze, or have trouble breathing during or

after activity?

Have you ever had surgery?

Do you have asthma?

Are you currently taking any prescription or nonprescription

(over-the-counter) medications or pills or using an inhaler?

Do you have seasonal allergies that require medical treatment?

Have you ever taken any supplements or vitamins to help you

Do you or does someone in your family have sickle cell trait or

gain or lose weight or improve your performance?

disease?

10.

Do you use any special protective or corrective equipment or

Do you have any allergies (for example, to pollen, medicine,

devices that aren’t usually used for your sport or position (for

food, or stinging insects)?

example, knee brace, special neck roll, foot orthotics, retainer

on your teeth, hearing aid)?

Have you ever had a rash or hives develop during or after

exercise?

11.

Have you had any problems with your eyes or vision?

Have you ever passed out during or after exercise?

Do you wear glasses, contacts, or protective eyewear?

Have you ever been dizzy during or after exercise?

Have you ever had a sprain, strain, or swelling after injury?

12.

Have you ever had chest pain during or after exercise?

Have you broken or fractured any bones or dislocated any

joints?

Do you get tired more quickly than your friends do during

exercise?

Have you had any other problems with pain or swelling in

muscles, tendons, bones, or joints?

Have you ever had racing of your heart or skipped heartbeats?

If yes, check appropriate box and explain below.

Have you had high blood pressure or high cholesterol?

Head

Elbow

Hip

Have you ever been told you have a heart murmur?

Neck

Forearm

Thigh

Back

Wrist

Knee

Has any family member or relative died of heart problems or

of sudden death before age 50?

Chest

Hand

Shin/calf

Shoulder

Finger

Ankle

Have you had a severe viral infection (for example,

Upper arm

Foot

myocarditis or mononucleosis) within the last month?

13.

Do you want to weigh more or less than you do now?

Has a physician ever denied or restricted your participation in

Do you lose weight regularly to meet weight requirements for

sports for any heart problems?

your sport?

Do you have any current skin problems (for example, itching,

14.

Do you feel stressed out?

rashes, acne, warts, fungus, or blisters)?

15.

Record the dates of your most recent immunizations (shots) for:

Have you ever had a head injury or concussion?

Tetanus _________________ Measles _________________________

Have you ever been knocked out, become unconscious, or lost

Hepatitis ________________ Chickenpox ______________________

your memory?

Explain “Yes” answers on a separate sheet.

Have you ever had a seizure?

Do you have frequent or severe headaches?

The above information is correct to the best of my knowledge. I hereby give my informed consent for the above-mentioned student to participate in activities. I understand

the risk of injury in athletic participation. If my son/daughter becomes ill or is injured, necessary medical care can be instituted by physicians, coaches, trainers or other

personnel properly trained. I further acknowledge and consent that, as a condition for participating in activities, identifying information about the above-mentioned student

may be disclosed to OSSAA in connection with any investigation or inquiry concerning the student’s eligibility to participate an/or any possible violation of OSSAA rules.

OSSAA will undertake reasonable measure to maintain the confidentiality of such identifying information, provided that such information has not otherwise been publicly

disclosed in some manner.

Signature of parent/guardian_____________________________________Signature of Athlete_________________________________________Date__________________