Pre-Participation History & Health Assessment Form

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The South Carolina Independent School Association
Pre-Participation History & Health Assessment Form
This form is to be filled out by the parent(s) and student prior to seeing the physician and presented to the
physician at the time of the student’s physical examination. The physician should keep this form with the
student’s records. A copy of this form will be submitted with the student's completed physical examination
form to the school.
Date that this form is being completed: _______________________________
Name __________________________________ Date of Birth: ____________________ Grade: _________
School: _________________________________ Sex: F ___ M ___ Sports: _________________________
Address: ____________________________________________________ Phone: ______________________
Personal Physician: __________________________________________ Phone: ________________________
In Case of an Emergency Contact: _________________________________ Relationship: ________________
Home Phone #: ______________________ Cell #: ______________________ Other: _________________
Attention parent or guardian and athlete: answers to the following questions are very important!
Please take the time to answer each question to the best of your knowledge.
Medicines and Allergies:
List all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are taking.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Do you have any allergies?
Yes
No
If yes, please identify specific al-
lergy
below.
Medicines
Pollens
Food
Stinging Insects
Other ____________________________________________
Please pro-
vide a
de-
scription of
cause and treatment:
________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Concussions:
Have you ever had a head injury or concussion?
Yes
No If yes, when (date): ____________________
Have you had more than one head injury or concussion?
Yes
No If yes, how many? _________
Provide the date of each concussion:
____________________________________________________________________
Have you ever had a blow to the head that caused confusion, prolonged headache, or memory loss?
Yes
No
Parent’s Permission & Acknowledgement of Risk for Son or Daughter to Participate in Athletics
As the parent or legal guardian of the above named student athlete, I give my permission for his/her participation in athletic events
and the physical evaluation for that participation. I grant permission for treatment deemed necessary for a condition arising during
participation in these events, including medical or surgical treatment that is recommended by a medical doctor. I grant permission to
nurses, trainers, coaches, doctors or those under their direction who are part of the athletic injury prevention or treatment, to have
access to necessary medical information. I know that the risk of injury to my child/ward comes with participation in sports and
during travel to and from play and practice. My signature indicates that to the best of my knowledge, my answers to the above
questions are complete and correct.
Signature of athlete ___________________________________________________ Date ________________________
Signature of parent/guardian ____________________________________________ Date ________________________

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