Parent Permission And Health History Form printable pdf download

Parent Permission and Health History

_____________________________

Student name

Sport_____________________________

PRIOR TO TRYOUTS

EACH

Parent/Guardian – complete and SIGN NO SOONER THAN

DAYS

for

SPORT SEASON!

History

Past Injuries

DOES YOUR CHILD HAVE:

Required medication?_____________________________ Head Injury/Concussion?_____________________

Allergies to medication?___________________________ Joint Injury?________________________________

Food Allergies?__________________________________ Extremities?________________________________

Environmental allergies?__________________________ Back Injury?_______________________________

Recent Hospitalizations?__________________________ Fractures?_________________________________

Disabilities?____________________________________ Sprains?___________________________________

Prosthetic devices?_______________________________

Medical Conditions

DOES YOUR CHILD HAVE:

PLEASE EXPLAIN ALL “YES” ANSWERS:

Fainting episodes?______________________________

_________________________________________

Headaches?____________________________________

_________________________________________

Asthma?______________________________________

_________________________________________

Issues with cold/heat?___________________________

_________________________________________

Neurologic problems?___________________________

_________________________________________

Cardiac problems?______________________________

_________________________________________

Any Other Condition?___________________________

_________________________________________

NYS LAW REQUIRES US TO PROVIDE YOU WITH INFORMATION ON CONCUSSIONS.

A concussion is a reaction by the brain, to a jolt or force that can be transmitted to the head by an impact or

blow occurring anywhere on the body. A concussion results from the brain moving back and forth or twisting

rapidly inside the skull.

Any student suspected of having a concussion either based on the disclosure of a head injury, observed or

reported symptoms, or by sustaining a significant blow to the head or body must be removed from athletic

activity and/or physical activities and observed until an evaluation can be completed by a medical provider.

Symptoms of concussion include but are not limited to:

• Amnesia (decreased or absent memory of

• Double or blurry vision

events prior to or immediately after the

• Sensitivity to light and/or sound

injury, or difficulty retaining new

• Nausea, vomiting, and /or loss of appetite

information)

• Irritability, sadness or other changes in

• Confusion or appearing dazed

personality

• Headache or head pressure

• Feeling sluggish, foggy, groggy, or

• Loss of consciousness

lightheaded

• Balance difficulty or dizziness, or clumsy

• Concentration or focusing problems

movements

CONTINUED ON BACK

Parent Permission And Health History Form

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