Interval Health History Form For Sports Participation
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1Office Use Only
School Physician Signature ________________________________
School Nurse Signature ________________________________
Date Cleared ________________
Date of Last Sports Physical _______________
Scotia-Glenville C.S.D.
Interval Health History Form for Sports Participation
Prior to the start of tryout sessions or practice at the beginning of each season, a health history review for each student
must be completed and turned in to the health office.
Part A- TO BE COMPLETED BY THE STUDENT
Student Name_________________________
Date of Birth_____________
Grade_______________
Age____________________
Sport________________________________
Modified
JV/Varsity (Please circle one)
Part B-TO BE COMPLETED BY THE PARENT OR GUARDIAN
NOTE: “YES” to any of these questions does not mean automatic disqualification from participation in sports.
However, it will require a review and approval by the school physician before the student can report to practice or
tryouts.
HISTORY SINCE LAST HEALTH APPRAISAL
If the answer to any of the following questions is “YES,” please describe the condition or situation that prompted your
answer, giving the date and doctor clearance in Part C.
1.
Any injuries requiring medical attention including,
concussion or loss of consciousness?
YES
NO
DATE______
2.
Any illness lasting more than 5 days?
YES
NO
DATE______
3.
Currently taking medication or under the care
of a physician for an active problem?
YES
NO
DATE______
4.
Any feelings of faintness, dizziness, fatigue,
or chest pain after exercise or exertion?
YES
NO
DATE______
5.
Change in wearing glasses or contact lenses?
YES
NO
DATE______
6.
Any fractures or surgical procedures?
YES
NO
DATE______
7.
Any treatment in a hospital or emergency room?
YES
NO
DATE______
8.
Developed any allergies, asthma exercise induced
asthma or reactions to medication?
YES
NO
DATE______
9.
Any chronic disease? (Diabetes, bleeding disorder
Seizures?)
YES
NO
DATE______
10.
Problems with heat exhaustion/heat fatigue?
YES
NO
DATE______
11.
Absence of or the significant impairment of one of
a pair of organs? (kidney, eye, ear, testicle)
YES
NO
DATE______
12.
Any history of sudden death in a family member
under the age of 50?
YES
NO
DATE______
PART C- TO BE COMPLETED BY PARENT OR GUARDIAN
Describe the condition or situation that caused you to answer “YES” to any question in PART B.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
PART D-PARENTAL PERMISSION
I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate in the
athletic sport 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_____________
Macintosh HD:Scotia website:Healthoffice:INTERVAL.DOC
HS-34
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