Ossaa Physical Examination And Parental Consent Form printable pdf download

OSSAA PHYSICAL EXAMINATION and PARENTAL CONSENT FORM

PLEASE PRINT

DATE OF EXAM ___________________

Name ______________________________________ Sex ______ Age ________ Date of Birth ____________________________

Grade ________ School ___________________________________________ Sport(s) ___________________________________

Address ________________________________________________________ __ Phone __________________________________

Personal Physician __________________________________________________ Phone __________________________________

In case of emergency, contact: Name _______________________________________ Relationship _________________________

Phone (H) ____________________________ (W) ____________________________ (C) _________________________________

Explain “Yes” answers below. Circle questions you don’t know the answers to.

YES NO

Have you had a medical illness or injury since your last check up or

Have you ever become ill from exercising in the heat?

sports physical?

Do you cough, wheeze, or have trouble breathing during or after activity?

Do you have an ongoing or chronic illness?

Do you have asthma?

Have you ever been hospitalized overnight?

Do you have seasonal allergies that require medical treatment?

Have you ever had surgery?

10.

Do you use any special protective or corrective equipment or devices that

Are you currently taking any prescription or nonprescription (over-the-

aren’t usually used for your sport or position (for example, knee brace,

counter) medications or pills or using an inhaler?

special neck roll, foot orthotics, retainer on your teeth, hearing aid)?

Have you ever taken any supplements or vitamins to help you gain or

11.

Have you had any problems with your eyes or vision?

lose weight or improve your performance?

Do you wear glasses, contacts, or protective eyewear?

Do you have any allergies (for example, to pollen, medicine, food or

12.

Have you ever had a sprain, strain, or swelling after injury?

stinging insects)?

Have you broken or fractured any bones or dislocated any joints?

Have you ever had a rash or hives develop during or after exercise?

Have you had any other problems with pain or swelling in muscles, ten-

Have you ever passed out during or after exercise?

dons, bone, or joints?

Have you ever been dizzy during or after exercise?

If yes, check appropriate box and explain below.

Have you ever had chest pain during or after exercise?

Head

Elbow

Hip

Neck

Forearm

Thigh

Do you get tired more quickly than your friends do during exercise?

Back

Wrist

Knee

Chest

Hand

Shin/calf

Have you ever had racing of your heart or skipped heartbeats?

Shoulder

Finger

Ankle

Upper Arm

Foot

Have you had high blood pressure or high cholesterol?

13.

Do you want to weigh more or less than you do now?

Have you ever been told you have a heart murmur?

Do you lose weight regularly to meet weight requirements for you sport?

Has any family member or relative died of heart problems or of sudden

14.

Do you feel stressed out?

death before age 50?

15.

Record the dates of your most recent immunization (shots) for:

Have you had a severe viral infection (for example, myocarditis or mono-

Tetanus ________________ Measles __________________

nucleosis) within the last month?

Hepatitis _______________ Chickenpox ________________

Has a physician ever denied or restricted your participation in sports for

Explain “Yes” answers here: _________________________________________

any heart problems?

_________________________________________________________________

Do you have any current skin problems (for example, itching, rashes,

acne, warts, fungus or blisters)?

_________________________________________________________________

Have you ever had a head injury or concussion?

_________________________________________________________________

Have you ever been knocked out, become unconscious, or lost your

_________________________________________________________________

memory?

_________________________________________________________________

Have you ever had a seizure?

Do you have frequent or severe headaches?

Have you ever had numbness or tingling in your arms, hands, legs, or

feet?

The above information is correct to the best of my knowledge. I hereby give my informed consent for the above-mentioned student to participate in activities. I

understand the risk of injury in athletic participation. If my son/daughter becomes ill or is injured, necessary medical care can be instituted by physicians, coaches,

trainers or other personnel properly trained.

Signature of parent/guardian ______________________________________________________ Date __________________________________

Signature of athlete ___________________________________________________________________

(complete back side)