Athletic Participation/parental Consent/physician'S Certificate Form - West Virginia Secondary School Activities Commission Page 2
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3PART III – STUDENT’S MEDICAL HISTORY
(To be completed by parent or guardian prior to examination)
Name ________________________________________________Birthdate _______/_______/_______ Grade ______ Age ______
Has the student ever had:
Does the student:
Yes No
1. Chronic or recurrent illness? (Diabetes, Asthma, Seizures,
Yes No 12. Have any problems with heart/blood pressure?
etc.,)
Yes No 13. Has anyone in your family ever fainted during exercise?
Yes No
2. Any hospitalizations?
Yes No 14. Take any medicine? List _________________________
Yes No
3. Any surgery (except tonsils)?
Yes No 15. Wear glasses ___, contact lenses___, dental appliances___?
Yes No
4. Any injuries that prohibited your participation in sports?
Yes No 16. Have any organs missing (eye, kidney, testicle, etc.)?
Yes No
5. Dizziness or frequent headaches?
Yes No 17. Has it been longer than 10 years since your last tetanus
Yes No
6. Knee, ankle or neck injuries?
shot?
Yes No
7. Broken bone or dislocation?
Yes No 18. Have you ever been told not to participate in any sport?
Yes No
8. Heat exhaustion/sun stroke?
Yes No 19. Do you know of any reason this student should not partici-
pate in sports?
Yes No
9. Fainting or passing out?
Yes No 20. Have a sudden death history in your family?
Yes No 10. Have any allergies?
Yes No 21. Have a family history of heart attack before age 50?
Yes No 11. Concussion? If Yes _____________________________
Yes No 22. Develop coughing, wheezing, or unusual shortness of breath
Date(s)
when you exercise?
PLEASE EXPLAIN ANY “YES” ANSWERS OR ANY OTHER
Yes No 23. (Females Only) Do you have any problems with your men-
ADDITIONAL CONCERNS.
strual periods.
I also give my consent for the physician in attendance and the appropriate medical staff to give treatment at any athletic event for any
injury.
SIGNATURE OF PARENT OR GUARDIAN ___________________________________________ DATE _______/_______/_______
PART IV – VITAL SIGNS
Height ___________________ Weight ____________________ Pulse ____________________ Blood Pressure _______________
Visual acuity: Uncorrected __________/__________; Corrected __________/__________; Pupils equal diameter: Y N
L
R
L
R
PART V – SCREENING PHYSICAL EXAM
This exam is not meant to replace a full physical examination done by your private physician.
Mouth:
Respiratory:
Abdomen:
Appliances
Y
N
Symmetrical breath sounds Y
N
Masses
Y
N
Missing/loose teeth
Y
N
Wheezes
Y
N
Organomegaly
Y
N
Caries needing treatment
Y
N
Cardiovascular:
Genitourinary (males only);
Enlarged lymph nodes
Y
N
Murmur
Y
N
Inguinal hernia
Y
N
Skin - infectious lesions
Y
N
Irregularities
Y
N
Bilaterally descended testicles
Y
N
Peripheral pulses equal
Y
N
Murmur with Valsalva
Y
N
Musculoskeletal: (note any abnormalities)
Neck:
Y
N
Elbow:
Y
N
Knee/Hip:
Y
N
Hamstrings:
Y
N
Shoulder:
Y
N
Wrist:
Y
N
Ankle:
Y
N
Scoliosis:
Y
N
RECOMMENDATIONS BASED ON ABOVE EVALUATION:
After my evaluation, I give my:
______ Full Approval;
______ Full approval; but needs further evaluation by Family Dentist _____; Eye Doctor _____; Family Physician _____; Other ____;
______ Limited approval with the following restrictions: __________________________________________________________;
______ Denial of approval for the following reasons: ____________________________________________________________.
____________________________________________________________________
_________/__________/__________
MD/DO/DC/Advanced Registered Nurse Practitioner/Physicians Assistant
Date
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