Ihsa - Preparticipation Examination Form Page 2
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2Student’s Name ___________________ School Name _____________________
Physical Examination
Height _____________
Weight_______________
Blood Pressure ______________
Consent Form to self administer asthma medication
Pulse: resting ______________ 15 hops______________ after 2 minutes______________
(not needed if current form is already on file with school)
Visual Acuity: Eyes (R) 20/ ________ w/o glasses ________
(L) 20/ ________ w/ glasses ________
Parent Consent
Other Testing
Normal
Abnormal Findings
1.
General
______________
_____________________________________________
I, ______________________________, do hereby give my son/daughter, ______________________________,
2.
Skin
______________
_____________________________________________
permission to self-administer his/her asthma medication as prescribed by his/her physician during
3.
HEENT
______________
_____________________________________________
athletic competition.
4.
Teeth (Dental Exam)
______________
_____________________________________________
________________________________________
___________________
5.
Neck
______________
_____________________________________________
Parent Signature
Date
6.
Lungs
______________
_____________________________________________
7.
Heart (Sit and Stand)
______________
_____________________________________________
Physician Consent
8.
Abdomen
______________
_____________________________________________
9.
Genitalia
______________
_____________________________________________
As a patient under my care, ________________________________, is prescribed to self-administer the
10.
Musculoskeletal
following asthma medication.
Neck
______________
_____________________________________________
Shoulder/Arm
______________
_____________________________________________
Medication_______________________________________________________________________________________
Elbow/Forearm
______________
_____________________________________________
Wrist/Hand
______________
_____________________________________________
Purpose__________________________________________________________________________________________
Back
______________
_____________________________________________
Dosage___________________________________________________________________________________________
Hip/Thigh
______________
_____________________________________________
Knee
______________
_____________________________________________
Time/Special Circumstances______________________________________________________________________
Shin/Calf
______________
_____________________________________________
__________________________________________________________________________________________________.
Ankle/Leg
______________
_____________________________________________
Foot
______________
_____________________________________________
________________________________________
___________________
11.
Peripheral Pulses
______________
_____________________________________________
Physician Signature
Date
12.
Neurologic
______________
_____________________________________________
13.
Mental Status
______________
_____________________________________________
IHSA Steroid Testing Policy Consent to Random Testing
14.
Marfan Screen
______________
_____________________________________________
In January 2008, the Illinois High School Association’s Board of Directors approved a plan
Other Tests (optional)
developed by the IHSA’s Sports Medicine Advisory Committee to implement random testing for
___________Auditory
___________U/V
___________EKG
steroids and performance-enhancing dietary supplements of teams and individuals qualifying for
___________% Body Fat
___________Drug Screen
___________Chest X-Ray
state finals competition.
___________Hgb/Hct
___________SMAC
___________Tanner Stage
Beginning with the 2008-09 school term, any student-athlete who ingests or otherwise uses
substance from the association’s banned drug classes, without written permission by a licensed
On the basis of the examination on this day, I approve this child’s participation in interscholastic
physician, to treat a medical condition, violates IHSA By-law 2.170 and its subsections, and is
sports for one year.
subject to IHSA penalties, including ineligibility from competition. The IHSA will test certain
Yes___________
No____________
Limited ____________
randomly selected individuals and teams that participate in state series competitions for banned
substances. The results of all tests shall be considered confidential and shall only be disclosed
to the student, his or her parents, and his or her school.
Additional Comments:
By signing below, we consent to random testing in accordance with the IHSA’s steroid testing
policy. We understand that, if the student or the student’s team participates in state series
competitions, the student may be subject to testing for banned substances.
No student-athlete may participate in IHSA state series competition unless the student and the
student’s parent/guardian consent to random testing.
Examination Date _______________ Physicians Signature __________________________________________
A complete list of the current IHSA Banned Drug Classes can be accessed at
Physician’s Assistant Signature* __________________________________________
Advanced Nurse Practitioner Signature* __________________________________________
________________________________________
___________________
Signature of student-athlete
Date
* effective January 2003, the IHSA Board of Directors approved a recommendation, consistent
with the Illinois School Code, that allows Physician’s Assistants or Advanced Nurse Practitioners
________________________________________
___________________
to sign off on physicals.
Signature of parent-guardian
Date
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