Interscholastic Sports Health History Update Form
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1GREAT NECK PUBLIC SCHOOLS
Health Services
Interscholastic Sports Health History Update “B” Form
____________________________________________________
_____________
_____
______
NAME
DATE of BIRTH
M / F
GRADE
TO PARTICIPATE IN INTERSCHOLASTIC SPORTS THE STUDENT MUST SUBMIT TO THE NURSE:
Physical Exam * The exam date must be within one year to the start of the sport season
“B” FORM {Health history UPDATE Form Signed by Parent/Guardian}
Each New Sport Season requires a “B” Form.
This “B” Form must be dated & returned to the Nurse NO earlier than 30 Days prior to the start of
EACH sport season
Health History To Be Completed By Parent/Guardian
Answer questions below to indicate if your child has or has ever had the following.
Y
Y
Provide details to any Yes answer on lines below:
Provide details to any Yes answer on lines below:
N
N
E
E
O
O
S
S
Ever been restricted by a doctor or nurse practitioner from sports
Ever had a hit to the head that caused a headache, dizziness,
participation for any reason?
nausea, or confusion or been told s/he had a concussion
Have an ongoing medical condition? Please check below:
Ever have headaches with exercise?
Asthma Diabetes Seizures Sickle Cell Trait or Disease Other
Ever had surgery?
Ever had a seizure?
Ever spent a night in the hospital?
Currently being treated for a seizure disorder or epilepsy?
Have a life threatening allergy?
Ever been unable to move his/her arms & legs, or had tingling,
numbness or weakness after being hit or falling?
Medication Food Insect bites Pollen Latex Other
Carry an Epinephrine Auto-Injector?
Ever had an injury, pain or swelling of joint that caused them to
miss practice or a game?
Ever passed out during or after exercise?
Use a brace, orthotic or other device?
Ever complained of light headedness or dizziness during or after
Have any problems with their hearing or wear hearing aids?
exercise?
Ever complained of chest pain, tightness, or pressure during or
Have any special devices or prostheses (insulin pump, glucose
after exercise?
sensor, ostomy bag, etc.)?
Ever complained fluttering in their chest, skipped beats, or their
Have any problems with their vision or have vision in one eye
heart racing, or does s/he have a pacemaker?
only?
Has student ever had a test for their heart? (i.e. EKG,
Wear glasses or contacts?
echocardiogram, stress test)
Ever been told they have a heart condition or problem?
Ever had a hernia?
Ever had high or low blood pressure?
Does s/he have only one (1) functioning kidney?
Ever complain of getting more tired or short of breath than
Does s/he have a bleeding disorder?
his/her friends during exercise?
Wheeze or cough frequently during or after exercise?
Did s/he have a fracture or break since last physical exam?
Ever been told by their health care provider they have Asthma?
Females Only: Has she had her period?____ At what age did it
begin?__ How often does she get her period_____? Last Menstrual
Use or carry an inhaler or Nebulizer?
Period______
Males Only: Does He only have one (1) testicle?
Ever become ill while exercising in hot weather?
On a special diet or have to avoid certain foods?
Family History: Has any relative been diagnosed with a heart condition
or developed hypertrophic cardiomyopathy, Marfan Syndrome, right
Have to worry about their weight?
Ventricular cardiomyopathy, long QT or short QT syndrome, Brugada
Syndrome, or catecholaminergic polymorphic ventricular tachycardia?
Have stomach problems?
Has any relative died suddenly before the age of 50 from an
unknown or heart related cause?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________(continue on back if necessary)
I certify that to the best of my knowledge my answers are complete and true.
I have reviewed the above information & give permission for my child to participate in
SPORT ____________________________________
Parent/Guardian Signature:
____________
Date: _____________
CLEARED FOR:_______________________________________________
School Nurse ____________________________ Date___________ Date of Physical ___________
B Form
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