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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

If yes, please identify specific allergy below.

Medicines

Pollens

Food

Stinging Insects

Other ____________________________________________

Please provide a description 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 con-

cussion? 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

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 ________________________

Pre-Participation History & Health Assessment Form - The South Carolina Independent School Association

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