Application For Participation (Medical Form) - Mississippi
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1
2APPLICATION FOR PARTICIPATION (Medical Form)
(must be completed and signed by licensed examiner every 3 years)
School/Agency:
/
/
SSN:
T-shirt Size:
Children:
OR
Adult:
AREA:
M or F
month/day/year
LAST NAME
FIRST
SEX
DATE OF BIRTH
/
/
Street Number/Address
Home Phone (
)
City
State
Zip Code
Parent/Guardian
Work Phone (
)
Address (if different)
City
State
Zip Code
Emerg. Phone (
)
Email address _________________________
Emergency Contact (other than parent/guardian)
Health Insurance Company
Ins. Policy #
Signature of parent/guardian/adult athlete completing form
FOR ATHLETES WITH DOWN SYNDROME – Persons with Down Syndrome should have a lateral x-ray of the cervical spine
in hyperflexion and hyperextension. the interpretation of the radiographs should include measurements of the atlanto-dens interval.
Yes
No
Has an x-ray evaluation for atlantoaxial instability been done?
Yes
No
If yes, was it positive for atlantoaxial instability? (positive indicates that the atlanto-dens interval is 5mm or more)
Heart problems/high blood pressure
Yes
Tobacco use
Yes
Emotional/psychiatric/behavioral problems
Yes
IS THERE PRESENT OR A HISTORY OF (to be completed by parent/caregiver):
Chest Pain
Yes
Major surgery or serious illness
Yes
Asthma/breathing problems with exertion
Yes
Seizures/epilepsy/fainting spells
Yes
Heat stroke/exhaustion
Yes
Contact lenses/glasses/dentures/false teeth
Yes
Diabetes
Yes
Easy bleeding
Yes
Head injury/history of concussion
Yes
Hearing aid/hearing problems
Yes
Bone/joint problems
Yes
Immunizations (shots) are up-to-date
Yes
Blindness/vision problem
Yes
Sickle cell disease or trait
Yes
Special Diet Needs (list below)
Yes
Absence of one kidney or testicle
Yes
Uses a wheelchair
Yes
Year of last tetanus shot
Other problems that would interfere with participation
Allergy to the following (list specific):
Food
Insect sting/bites
Medication
Medication Name
Dosage
Date Presc.
Times per day
Medication Name
Dosage
Date Presc.
Times per day
MEDICATIONS
PHYSICAL EXAMINATION
Blood Pressure
Vision
Oral Cavity
Cardiovascular system
Normal
Abnormal
Normal
Abnormal
Normal
Abnomal
Pulse
Hearing
Extremities
Respiratory system
Weight
Neck
Coordination
Gastrointestinal system
Height
Skin
Reflexes
Genitourinary system
Cranial nerves
Other:
Primary MR Etiology/Category
I have reviewed the above health information and examined the athlete named in the application and certify that there is no medical evidence available to me which would
preclude the athlete’s participation in Special Olympics.
Restrictions
Examiner’s Name
Certification:
MD
ARNP
EXAMINER’S SIGNATURE
DATE:
Asian
African American
OPTIONAL INFORMATION
Caucasian
Hispanic
Native American
Other
Ethnic background:
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Parent category: Medical