Ms Athletic Participation Form

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DO NOT FOLD FORM
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
I I
Heart Attack
________________________________________________________________________
I I
I I
Sudden Death
________________________________________________________________________
I I
I I
Stroke
________________________________________________________________________
I I
I I
Heart Disease / High Pressure
________________________________________________________________________
I I
I I
Diabetes
________________________________________________________________________
I I
I I
Sickle Cell Anemia
________________________________________________________________________
I I
I I
Arthritis
________________________________________________________________________
I I
I I
Epilepsy
________________________________________________________________________
I I
I I
Kidney Disease
________________________________________________________________________
ATHLETE’S ORTHOPAEDIC HISTORY
Has the athlete had any of the following injuries?
Yes
No
Condition
Date
Yes
No
Condition
Date
I I
I I
I I
I I
Head Injury / Concussion
____________________
Neck Injury / Stinger
____________________
I I
I I
I I
I I
Shoulder L / R
____________________
Arm / Wrist / Hand L / R
____________________
I I
I I
I I
I I
Elbow L / R
____________________
Back
____________________
I I
I I
I I
I I
Hip
____________________
Thigh L / R
____________________
I I
I I
I I
I I
Knee L / R
____________________
Lower Leg L / R
____________________
I I
I I
I I
I I
Chronic Shin Splints
____________________
Ankle L / R
____________________
I I
I I
I I
I I
Foot L / R
____________________
Severe Muscle Strain
____________________
I I
I I
I I
I I
Pinched Nerve
____________________
Chest
____________________
Previous Surgeries: __________________________________________________________________________________________________
ATHLETE’S MEDICAL HISTORY
Has the athlete had any of these conditions?
I I
I I
I I
I I
Yes
No
Condition
Organ Loss
Overnight in hospital
I I
I I
I I
I I
I I
I I
Heart Murmur
Shortness of breath / coughing
Hernia
I I
I I
I I
I I
Seizures
during exercise
Rapid weight loss / gain
I I
I I
I I
I I
I I
I I
Kidney Disease
Knocked out
Take supplements / vitamins
I I
I I
I I
I I
I I
I I
Irregular Pulse
Heart Disease
Heat related problems
I I
I I
I I
I I
I I
I I
Single Testicle
Diabetes
Menstrual irregularities
I I
I I
I I
I I
I I
I I
High Blood Pressure
Liver Disease
Recent Mononucleosis /
I I
I I
I I
I I
Dizzy / Fainting
Tuberculosis
Enlarged Spleen
I I
I I
Surgery - What Type? _____________________________________________________________________________________
I I
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
FILL IN AT TIME OF PHYSICAL
This waiver, executed this ________ day of __________________, 200______, by ________________________________________, 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)
Information below to be filled out by physician only
Height __________________
Weight __________________
Blood Pressure __________________
Pulse __________________
Orthopaedic Exam
General Medical Exam
Norm
Abnl
Norm
Abnl
Norm
Abnl
I.
Spine / Neck
_______ _______
ENT
_______ _______
Lungs
_______ _______
Cervical
_______ _______
Heart
_______ _______
Abdomen
_______ _______
Thoracic
_______ _______
Skin
_______ _______
Hernia (if Needed)
_______ _______
Lumbar
_______ _______
General Health Comments _____________________________________________________
__________________________________________________________________________
II.
Upper Extremity
_______ _______
__________________________________________________________________________
Shoulder
_______ _______
FLEXIBILITY
LEFT
RIGHT
FLEXIBILITY
LEFT
RIGHT
Elbow
_______ _______
Neck
_______ _______
Shoulder
_______ _______
Wrist
_______ _______
Hips
_______ _______
Quads
_______ _______
Hand / Fingers
_______ _______
Hams
_______ _______
Heelcords
_______ _______
III. Lower Extremity
_______ _______
Back Ext / Flex
_______ _______
Hip
_______ _______
Knee
_______ _______
Comments _________________________________________________________________
Ankle
_______ _______
__________________________________________________________________________
Feet
_______ _______
__________________________________________________________________________
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
______________________________________________________
___________________________________________________, M.D.
Typed or Printed Name of Physician
Signature of Physician
PHYSICIAN - WHITE SCHOOL - CANARY PARENT/GUARDIAN - PINK
DO NOT FOLD FORM
MSMOC 62 Rev. 3/03

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