Idaho Health Examination And Consent Form
ADVERTISEMENT
1
2Idaho High School Activities Association
Idaho Health Examination and Consent Form
th
th
It is required that all students complete a History and Physical examination prior to his/her first 9
and 11
grade practice in the interscholastic
th
th
(9-12) athletic program in the State of Idaho. The exam is at the expense of the student and may not be taken prior to May 1 of the 8
and 10
grade years. This examination is to be done by a licensed physician, physician's assistant or nurse practitioner under optimal conditions.
th
th
Interim history forms are required during the 10
and 12
grade years and must be submitted to the principal prior to the first practice.
Name
Home Address
Phone
Grade
Sports
Personal Physician
Physician's Phone Number
Date of Birth
Sex
School
History Form
Fill in details of "YES" answers in space below:
YES
NO
YES
NO
1. A. Have you ever been hospitalized?
5. Do you have any skin problems?
B. Have you ever had surgery?
(itching, rash, acne)
2. Are you presently taking any medication
6. A. Have you ever had a head injury?
or pills?
B. Have you ever been knocked out or
3. Do you have any allergies
unconscious?
(medicine, bees, other stinging insects)?
C. Have you ever been diagnosed with
4. A. Have you ever passed out during or
a concussion?
after exercise?
D. Have you ever had a seizure?
B. Have you ever been dizzy during or
E. Have you ever had a stinger, burner,
after exercise?
or pinched nerve?
C. Have you ever had chest pain during or
7. A. Have you ever had heat cramps?
after exercise?
B. Have you ever been dizzy or passed
D. Do you tire more quickly than your
out in the heat?
friends during exercise?
8. Do you have trouble breathing or
E. Have you ever had high blood pressure?
cough during or after exercise?
F. Have you ever been told you have a
9. Do you use special equipment, pads,
heart murmur?
braces, mouth or eyeguards?
G. Have you ever had racing of your heart
10. A. Have you had problems with your
or skipped beats?
eyes or vision?
H. Has anyone in your family died of heart
B. Do you wear glasses, contacts, or
problems or a sudden death before age 50?
protective eyewear?
11. Were you born without a kidney, testicle, or any other organ?
12. Have you ever sprained/strained, dislocated, fractured/broken, or had repeated swelling or other injuries of any of your bones or joints?
____ Head
____ Neck
____ Chest
____ Back
____ Hip
____ Shoulder
____ Elbow
____ Forearm
____ Wrist
____ Hand
____ Thigh
____ Knee
____ Shin/Calf
____ Ankle
____ Foot
13. Have you ever had any other medical problems such as:
____ Mononucleosis
____ Diabetes
____ Asthma
____ Hepatitis
____ Headaches (frequent)
____ Eye Injuries
____ Other
14. Have you had a medical problem or injury since your last exam?
15. When was your last tetanus shot?
When was your last measles immunization? ___________________________________
16. When was your first menstrual period?
When was your last menstrual period?
What was the longest time between periods last year?
Explain "YES" answers here:
Consent Form
(Parent or Guardian and Student Permission and Approval)
I hereby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent
includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated
by school authorities for any illness or injury resulting from his/her athletic participation. I also consent to the release of any information
contained in this form to carry out treatment and healthcare operations for the above named student.
PARENT OR GUARDIAN SIGNATURE____________________________________________________
DATE:________________
This application to compete in interscholastic athletics for the above school is entirely voluntary on my part and is made with the understanding
that I have not violated any of the eligibility rules and regulations of the State Association.
SIGNATURE OF STUDENT__________________________________________________________
DATE:________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical