State Of Illinois Certificate (Page 2 of 2) in pdf

Physical Examination

Student’s Name

School Name

Consent Form to Self-Administer Asthma Medication

Height

Weight

Blood Pressure

(not needed if current form is already on file with school)

Pulse: resting

15 hops

after 2 minutes resting

Parent Consent

Visual Acuity: Eyes (R) 20/

w/o glasses

(L) 20/

w/glasses

, do hereby give my son/daughter,

Permission to self-administer his/her asthma medication as prescribed by his/her physician during

Other Testing

Normal

Abnormal Findings

athletic competition.

General

Skin

HEENT

Parent’s Signature

Date

Teeth (Dental Exam)

Neck

Physician Consent

Lungs

As a patient under my care,

, is prescribed to self-administer the

Heart (Sit and Stand)

following asthma medication.

Abdomen

Genitalia

Medication

10.

Musculoskeletal

Neck

Purpose

Shoulder/Arm

Elbow/Forearm

Dosage

Wrist/Hand

Back

Time/Special Circumstances

Hip/Thigh

Knee

Shin/Calf

Ankle/Leg

Foot

11.

Peripheral Pulses

Physician’s Signature

Date

12.

Neurologic

IHSA Steroid Testing Policy Consent to Random Testing

13.

Mental Status

14.

Marfan Screen

In January 2008, the Illinois High School Association’s Board of Directors approved a plan developed

by the IHSA’s Sports Medicine Advisory Committee to implement random testing for steroids and

performance-enhancing dietary supplements of teams and individuals qualifying for state finals

Other Tests (optional)

competition.

Auditory

U/V

EKG

% Body Fat

Drug Screen

Chest X-Ray

Beginning with the 2008-09 school term, any student-athlete who ingests or otherwise uses

Hgb/Hct

SMAC

Tanner Stage

substance from the association’s banned drug classes, without written permission by a licensed

physician, to treat a medical condition, violates IHSA By-law 2.170 and its subsections, and is subject

On the basis of the examination on this day, I approve this child’s participation in interscholastic

to IHSA penalties, including ineligibility from competition.

The IHSA will test certain randomly

sports for one year.

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

Yes

Limited

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

Physician’s Signature

A complete list of the current IHSA Banned Drug Classes can be accessed at

Physician’s Assistant Signature*

Advanced Nurse Practitioner’s Signature*

*effective January 2003, the IHSA Board of Directors approved a recommendation, consistent with

Signature of student-athlete

Date

the Illinois School Code, that allows Physician’s Assistants or Advanced Nurse Practitioners to sign

off on physicals.

Signature of parent-guardian

Date

State Of Illinois Certificate Page 2

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