Lhsaa Medical History Evaluation

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LHSAA MEDICAL HISTORY EVALUATION
I. IMPORTANT:
This form must be completed annually, kept on file with the school, & is subject to inspection by the Rules Compliance Team.
Please Print
Name:_______________________________________ School:__________________________________ Grade:______ Date:__________
Sport(s):___________________________________________ Sex: M / F Date of Birth:_________ Age:____ Cell Phone:______________
Home Address:__________________________ City:___________________ State:___ Zip Code:________ Home Phone:______________
Parent / Guardian:___________________________________ Employer:______________________________ Work Phone:____________
FAMILY MEDICAL HISTORY:
Has any member of your family under age 50 had these conditions?
Yes No Condition
Whom
Yes No Condition
Whom
Yes No Condition
Whom
Heart Attack /Disease _______________
Sudden Death
_______________
Arthritis
_______________
p p
p p
p p
p p
Stroke
_______________
p p
High Blood Pressure
_______________
p p
Kidney Disease
_______________
p p
Diabetes
_______________
p p
Sickle Cell Trait/Anemia
_______________
p p
Epilepsy
_______________
ATHLETE’S ORTHOPAEDIC HISTORY:
Has the athlete had any of the following injuries?
Yes No Condition
Dates
Yes No Condition
Dates
Yes No Condition
Dates
Neck Injury / Stinger
___________
Shoulder L / R
____________
p p
Head Injury / Concussion
___________
p p
p p
p p
Elbow L / R
___________
p p
Arm / Wrist / Hand L / R
___________
p p
Back
____________
p p
Hip L / R
___________
p p
Thigh L / R
___________
p p
Knee L / R
____________
Lower Leg L / R
___________
p p
Chronic Shin Splints
___________
p p
Ankle L / R
____________
p p
Foot L / R
___________
p p
Severe Muscle Strain
___________
p p
Pinched Nerve
____________
p p
p p
Chest
___________
Previous Surgeries: ______________________________________________________________________
ATHLETE’S MEDICAL HISTORY: Has the athlete had any of these conditions?
Yes No Condition
Yes No Condition
Yes No Condition
Heart Murmur / Chest Pain / Tightness
p p
p p Asthma / Prescribed Inhaler
p p
Menstrual Irregularities: Last Cycle:_____________
p p
Seizures
p p Shortness of breath / Coughing
p p
Rapid weight loss / gain
p p
Kidney Disease
p p Hernia
p p
Take supplements/vitamins
p p
Irregular Heartbeat
p p Knocked out / Concussion
Heat related problems
p p
p p
Single Testicle
p p Heart Disease
Recent Mononucleosi
p p
High Blood Pressure
p p
p p Diabetes
p p
Enlarged Spleen
Dizzy / Fainting
p p
p p Liver Disease
p p
Sickle Cell Trait/Anemia
p p
Organ Loss (kidney, spleen, etc.)
p p Tuberculosis
p p
Overnight in hospital
p p
Surgery
p p Prescribed EPI PEN
p p
Allergies (Food, Drugs)_________________________
Medications:___________________________________________________________________________________________________________________________
p
p
List Dates for: Last Tetanus Shot: ________________________ Measles Immunization:_________________________ Meningitis Vaccine: ___________________________
WAIVER FORM
To the best of our knowledge, we have given true & accurate information & 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 if the
examination is provided without expectation of payment, there shall be no cause of action pursuant to Louisiana R.S. 9:2798 against the team volunteer
healthcare provider and/or employer under Louisiana law.
1. If, in the judgement of a school representative, the named student athlete needs care or treatment as a result of an injury.
or sickness, I do hereby request, consent and authorize for such care as may be deemed necessary.......................................................... Yes
No
2. I understand that if the medical status of my child changes in any significant manner after his/her physical examination,
I will notify his/her principal of the change immediately...................................................................................................................................Yes
No
3. I give my permission for the athletic trainer to release information concerning my child’s injuries to the head coach/athletic
director/principal of his/her school...................................................................................................................................................................Yes
No
This waiver, executed this____ day of ________________, 20___, by____________________, M.D., D.O., APRN or PA and _________________________,
student athlete, is executed in compliance with Louisiana law with the full understanding that there shall be no cause of action for any loss or damage caused
by any act or omission related to the health care services if rendered voluntarily and without expectation of payment herein unless such loss or damage was
caused by gross negligence.
_____________________________________
______________________________________
__________________________________
Typed or Printed Name of Student Athlete
Signature of Parent
Typed or Printed Name of Parent
II. COMPLETED ANNUALLY BY MEDICAL DOCTOR (MD), OSTEOPATHIC DR. (DO), NURSE PRACTITIONER (APRN) OR PHYSICIAN ASSISTANT (PA)
Height _____________
Weight __________________
Blood Pressure _______________
Pulse __________
GENERAL MEDICAL EXAM:
OPTIONAL EXAMS:
ORTHOPAEDIC EXAM:
Norm
Abnl
Norm
Abnl
VISION:
I.
Spine / Neck
p
p
ENT
p
p
L:________ R:________ Corrected: ________
Cervical
p
p
Lungs
p
p
Thoracic
p
p
Heart
p
p
DENTAL:
Lumbar
p
p
Abdomen
p
p
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
II.
Upper Extremity
p
p
Skin
p
p
31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Shoulder
p
p
Hernia (if needed)
p
p
Elbow
p
p
Wrist
p
p
COMMENTS:_______________________________________________________________________
Hand / Fingers
p
p
__________________________________________________________________________________
III.
Lower Extremity
p
p
__________________________________________________________________________________
Hip
p
p
Knee
p
p
From this limited screening I see no reason why this student cannot particpate in athletics
Ankle
p
p
[ ] Student is cleared
[ ] Cleared after further evaluation and treatment for:________________________________________
[ ] Not cleared for: __contact
___non-contact
_______________________________________
_______________________________________________
_____________________________
Printed Name of MD, DO, APRN or PA
Signature of MD, DO, APRN, or PA
Date
*This physical expires one year on the last day of the month that it was signed and dated by the MD, DO, APRN or PA.*

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