Piaa Recertification Forms
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1
2SECTION 5: PIAA RE-CERTIFICATION BY PARENT/GUARDIAN
This is not a physical form. This is for those who already had a sports physical for the current academic year and will be going
to play a winter or spring sport. This form should only be completed by the parent/guardian of any student who (1) previously
participated in a PIAA interscholastic sport for the current school year and completed a Comprehensive Initial Pre-Participation
Physical Evaluation (CIPPE) for that sport for the current school year; and (2) is seeking to participate in practices, inter-school
practices, scrimmages, and/or contests in a subsequent sport(s) in the same school year. The Certified Athletic Trainer must review the
SUPPLEMENTAL HEALTH HISTORY and make a determination as to whether the student should be re-evaluated and re-certified
by a licensed physician of medicine or osteopathic medicine.
SUPPLEMENTAL HEALTH HISTORY
Student’s Name ________________________________________________ Age ________________ Grade ____________________
Winter or Spring Sport to be play:________________________________________________________________
CHANGES TO PERSONAL INFORMATION: In the spaces below, identify any changes to the Personal Information set forth in
the original Comprehensive Initial Pre-Participation Examination form. PLEASE LIST CHANGES ONLY.
Current Home Address ________________________________________________________________________________________
Current Telephone # H(_____ ) ________________________W (_____ ) ____________________C (_____ ) __________________
CHANGES TO EMERGENCY INFORMATION
Emergency Contact____________________________________________ Relationship_____________________________________
Emergency Contact Phone H (_____)____________________W (_____)_____________________C (_____)___________________
Emergency Contact 2 __________________________________________Relationship______________________________________
Emergency Contact 2 Phone H (_____)___________________W (_____)____________________ C (_____)___________________
Family Physician ___________________________________Family Physician Address ____________________________________
Medical Insurance Carrier______________________________
SUPPLEMENTAL HEALTH HISTORY: Explain “Yes” answers at the bottom of this form.
Since your last sports physical:
Yes
No
Yes
No
1. Since completion of the CIPPE, have you
4.
Since completion of the CIPPE, have you
sustained an illness and/or injury that
experienced any episodes of unexplained
required medical treatment form a licensed
shortness of breath, wheezing, and/or chest
physician of medicine or osteopathic medicine?
Y
N
pain?
Y
N
2. Since completion of the CIPPE, have you had
5.
Since completion of the CIPPE, are you
a concussion (i.e. bell rung, ding, head rush)
taking any NEW prescription or non-
or head injury
Y
N
prescription medicines or pills
Y
N
3. Since completion of the CIPPE, have you
6.
Do you have any concerns that you would
Experienced dizzy spells, blackout, and/or
like to discuss with a doctor?
Y
N
unconsciousness
Y
N
Explain “Yes” answers here: ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Student’s Signature _________________________________________________________________________Date____/____/_____
Parent’s/Guardian’s Signature _________________________________________________________________Date____/____/_____
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