Mus Pre-Participation Medical History Form - 2016-2017 (Page 8 of 8) in pdf

Mus Pre-Participation Medical History Form - 2016-2017 Page 8



The immediate removal of any youth athlete who passes out or faints while participating

in an athletic activity, or who exhibits any of the following symptoms:

(i) Unexplained shortness of breath;

(ii) Chest pains;

(iii) Dizziness

(iv) Racing heart rate; or

(v) Extreme fatigue; and



Establish as policy that a youth athlete who has been removed from play shall not return

to the practice or competition during which the youth athlete experienced symptoms

consistent with sudden cardiac arrest



Before returning to practice or play in an athletic activity, the athlete must be evaluated

by a Tennessee licensed medical doctor or an osteopathic physician. Clearance to full or

graduated return to practice or play must be in writing.

I have reviewed and understand the symptoms and warning signs of SCA.

Print Student-Athlete’s Name Date

Signature of Student-Athlete

_____________________________

_________________________ __________

Print Parent/Guardian’s Name Date

Signature of Parent/Guardian

Mus Pre-Participation Medical History Form - 2016-2017 Page 8