Interval Health History For Sports Participation printable pdf download

Interval Health History For Sports Participation

INTERVAL HEALTH HISTORY FOR SPORTS PARTICIPATION

COMMACK SCHOOL DISTRICT

Prior to the beginning of each season, a health history review for each athlete must be given

to the coach at their pre-season meeting. This form must be on file in the nurse's office in

order for an athlete to be eligible to participate.

PART A - TO BE COMPLETED BY THE STUDENT (PLEASE PRINT)

Student______________________________________________________________________________

Last Name

First Name

Date of Birth ________________________________ Age_____________

Grade (check) _____6 _____7 _____8 _____9 _____10 _____11 _____12

Sport________________________________________________________________________________

Season: Fall_______ Early Winter_______ Winter_______ Late Winter_______ Spring_______

PART B - TO BE COMPLETED BY THE PARENT OR GUARDIAN

Note: "YES" to any of these questions does not mean automatic disqualification from the athletic activity

indicated in PART A above. However, it will require a review and approval by the school physician before

the student can report to practice or tryouts.

HISTORY SINCE LAST SPORTS PHYSICAL:

If the answer to any of the following questions is "YES" please explain below:

YES

1) Any injuries requiring medical attention?

___

2) Any illness lasting more than five (5) days and/or requiring medical attention?

___

3) Taking medicine or under physician’s care at this time?

___

4) Any feeling of faintness, dizziness or fatigue after exercise or exertion?

___

5) Change in wearing glasses or contact lens?

___

6) Any surgical operations or fractures?

___

7) Any treatment in a hospital or emergency room?

___

8) Developed any allergies?

___

9) Any chronic disease?

___

PART C - TO BE COMPLETED BY PARENT OR GUARDIAN

I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely

participate on the athletic team named in PART A of this form. The answers are correct as of this date and

he/she has my permission to participate.

Signed______________________________________________________Date_______________

Interval Health History For Sports Participation