Students Medial History Form - Department Of Health, The City Of New York
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2DEPARTMENT OF HEALTH * THE CITY OF NEW YORK * BOARD OF EDUCATION
INTERSCHOLASTIC * SPORTS EXAMINATION * - CONFIDENTIAL
SHADED SECTION MUST BE COMPLETED BY THE PARENT/GUARDIAN
OSIS # ____ ____ ____ - ____ ____ ____ - ____ ____ ____
ID # ____ ____ ____ ____
NAME: _____________________________________________
SCHOOL: _______________ BOROUGH: ________
ADDRESS: _________________________________________
HOMEROOM: ________________
GRADE: ______
___________________________________________________
DATE OF BIRTH: ____________________________________
TELEPHONE #: (_______) ______________________
EMERGENCY PHONE #: (_______) ______________________
CELL PHONE #: (_______) _____________________
SPORT: ____________________________________________
SPORT: _____________________________________
PARENTAL PERMISSION: I have reviewed the STUDENTS MEDIAL HISTORY section below and I agree with the answers. I
give permission for ____________________________________________________ to have a physical examination.
SIGNATURE: _________________________________ DATE: ______________________________
RELATIONSHIP: ______________________________
THIS SECTION IS TO BE COMPLETED BY PHYSICIAN
CLINCIAN’S RECOMMENDATIONS
Based on my review of the history and physical examination as noted below and on the back of the form, and review of the
guidelines regarding athletic participation, this student:
May participate in the following sports:
DRAW A LINE THROUGH ANY SPORTS TO BE OMITTED:
CONTACT
ENDURANCE
OTHER
Football
Gymnastics
Bowling
Baseball
Swimming
Gold
Basketball
Track & Field
Archery
Soccer
Cross-Country
Field Events
Hockey
Tennis
Cheerleading
Wrestling
Volleyball
Lacrosse
Handball
: ________
DATE OF LAST TETANUS BOOSTER
Special conditions for participation (e.g. pre-exercise mediation or protective equipment), if any:
DATE: ______________________________
SIGNATURE: _________________________________
TELEPHONE #: (_______) ______________________
NAME (
): _______________________________
PRINT
ADDRESS: __________________________________
REGISTRY #: ______________________________
____________________________________________
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN:
CLINICIAN’S COMMENTS:
Has anyone in your family under age
Died suddenly?
Yeso
Noo
_____________________________________
Have you ever had:
Concussion or been knocked out?
Yeso
Noo
_____________________________________
Fainting?
Yeso
Noo
_____________________________________
Heat Stroke?
Yeso
Noo
_____________________________________
Epilepsy, seizures, or fits?
Yeso
Noo
_____________________________________
Head or neck injury?
Yeso
Noo
_____________________________________
Very bad vision in one or both eyes?
Yeso
Noo
_____________________________________
Do you wear glasses, contacts, other?
Yeso
Noo
_____________________________________
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Parent category: Medical