School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana
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4STATE OF LOUISIANA
SCHOOL ENTRANCE & GENERAL HEALTH EXAM FORM/
LHSAA MEDICAL HISTORY EVALUATION
nd
rd
th
See instructions on page 4. LHSAA student athletes using this form for their 2
, 3
or 4
years of eligibility are only required to
show changes on this form.
PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE.
State law (R.S. 17:170) requires that all persons entering any
school for the first time be up to date in their immunizations. Important: This form must be kept on file with the school and is subject to inspection by the LHSAA
Rules Compliance Team. It is important to keep all contact information current at all times.
Name of School:
Grade:
Student’s Name:
Last
First
M.I.
Student’s Date of Birth:
❑ M
❑ F
State or Country of Birth:
Sex:
Student’s Mailing Address:
City:
State:
Zip Code:
Student’s Physical Address:
City:
State:
Zip Code:
Name of Mother or Legal Guardian:
Home Phone:
Work Phone:
Cell Phone:
Employer:
(
)
(
)
(
)
Name of Father or Legal Guardian:
Home Phone:
Work Phone:
Cell Phone:
Employer:
(
)
(
)
(
)
❑
❑
Medicaid/LaCHIP
❑
Please check the type of health insurance your child has:
Private
None
❑
❑
No
If your child does not have health insurance, would you like information on no cost health insurance?
Yes
In case of emergency—if parent or legal guardian cannot be contacted—contact the following:
Name
Complete Phone Number
(
)
PART 2: PARENT OR LEGAL GUARDIAN TO COMPLETE.
Below is an assessment of your child’s health. To the best of
your knowledge, has your child had any problems with the following? Please check yes or no.
General Health Questions
Yes
No
Comments if “Yes” and date of last occurrence
Had/have a medical problem or injury since last evaluation?
Ever not been allowed to participate in sports for a medical
reason?
Have any missing organs? (eye, kidney, testicle, etc.)
Been dizzy or passed out during or after exercise?
Had/have chest pain during or after exercise?
Tire more quickly than his/her friends during exercise?
Have a family member that died of heart problems before
age 50?
Had/have a family member with sudden death before age
50?
Ever been knocked out or unconscious?
Ever had a stinger, burner or pinched nerve?
Ever had heat cramps?
Ever been dizzy or passed out in the heat?
Have trouble with breathing or coughing during or after
activity?
Ever sprained/strained, dislocated, fractured bones or joints?
Ever had repeated swelling of any bones or joints?
Use any special equipment? (pads, braces, neck rolls, eye
guards, kidney belt, etc.)
Condition
Yes
No
Comments if “Yes” and date of last occurrence
Anemia
Allergies (food, insects, medications, latex)
Allergies (seasonal)
Asthma or breathing problems
Attention-Deficit/Hyperactivity Disorder
Behavioral problems
Chicken Pox
Developmental problems
Bladder problem
Bleeding problems
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