School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation

Name: ____________________

DOB: ________

Condition

Yes

Comments if “Yes” and date of last occurrence

Bowel problem

Cerebral Palsy

Cystic Fibrosis

Dental problems

Diabetes

Head or spinal Injury

Hearing problems or deafness

Heart problems

Racing of the heart or skipped heartbeats

Hepatitis

High blood pressure

Hospitalizations (when, why)

Lead poisoning

Mononucleosis

Muscular problems

Rheumatic Fever

Seizures

Sickle Cell Disease (not trait)

Skin problems

Speech problems

Surgery

Tuberculosis

Vision problems

Other:

List all prescription and over-the-counter medications your child takes regularly:

Describe any other important health-related information about your child (i.e., feeding tube, oxygen support, hearing aid, etc.):

Name of your child’s pediatrician or primary care

Names of medical specialists or special clinics caring for your child:

provider:

❑ Yes

❑ No

If yes, date of last appointment:

Has your child ever seen a dentist?

Name of your child’s dentist:

For Parents/Legal Guardians of Students

The information on this form is current and correct to the best of my knowledge. I understand that if the medical status of my child

changes in any significant manner after his/her physical examination, I will notify his/her school nurse of the change immediately. In

an emergency medical situation, I give permission for the school nurse or other school authority to share protected health information

related to the emergency with the emergency contact.

For Parents/Legal Guardians of the Student Athlete Only

I give my permission for my child to be examined for school-related activities and for this information and the completed physical

examination report to be shared with school personnel and those affiliated with the team on a need to know basis. If, in the judgment

of a school representative, the named student athlete needs care or treatment as a result of an injury or sickness, I do hereby request,

consent and authorize for such care and exchange of information as may be deemed necessary. I recognize the evaluation to be

done on my child is a standard pre-participation screening examination, and that no in-depth testing, x-rays, lab work, or cardiac

testing will be performed unless deemed necessary by the health care examiner. I give my permission for the athletic trainer to

release information concerning my child’s injuries to the head coach/athletic director/principal of his/her school. I give my permission

for the athletic trainer, head coach, athletic director/principal of his/her school to release information concerning my child’s medical

examination, injuries or medical conditions to any medical provider who treats my child for a school-related or athletic injury or who is

treating my child at my selection for any condition.

By signing below, I am agreeing to the above.

Signature of Parent or Legal Guardian:

Date:

Signature of Interpreter (if applicable):

Date:

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School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana Page 2

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