Health Assessment Sports Physical Statement
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1
2HEALTH ASSESSMENT/SPORTS PHYSICAL STATEMENT (HASPS)
for CYS SERVICES
ENROLLMENT, Renewal & SPORTS PHYSICAL Requirements
Revised 08Jan 09
DATA REQUIRED BY THE PRIVACY ACT OF 1994
PRINCIPAL PURPOSE: Information is used by DA personnel to: (1) verify child health status of immunization per admission requirements; (2) note
special program considerations or restriction on child participation; (3) execute emergency medical procedure for chronic illnesses/conditions; (4) refer
child for enrollment in Exceptional Family Member Program; (5) certify physically fit to participate in sports. ROUTINE USES: No information is disclosed
outside DOD. DISCLOSURE: Information is voluntary; however, if information is not provided, individuals may not be able to participate in community
activities.
INSTRUCTIONS: All sections A, B, C. must be completed
PART: A
Medical History (Filled out by parent / guardian)
Name of Sponsor
Home Telephone
Duty/Work Telephone
Cell Telephone
Sponsor Unit / Work Address
Sponsor SSN
Spouse’s Work Telephone
CHILD HEALTH INFORMATION
Name of Child
Birth Date
Sex
Male
Female
Does your child have ongoing medical concerns?
(If Yes, explain circumstances and current status)
Yes
No
Is your child enrolled in Exceptional Family Member Program?
(If Yes, explain)
Yes
No
MEDICAL HISTORY
YES
NO
YES
NO
1. Any hospitalization or operations
14. Heat stroke or exhaustion
2. Allergies to medicine, insect bites or food
15. Broken bones or sprains
3. Speech or development delays
16. Joint injuries (Ankle/Knee/Wrist)
4. Vision Problems (Glasses / Contacts)
17. Required restricted physical activity
5. Ear or hearing problems
18. Diabetes
6. Seizures or Convulsions
19. Cancer
7. Dizziness or fainting with exercise
20. Dental or orthodontic braces
8. Headaches
21. Learning problems
9. Head injury or loss of consciousness
22. Sleep problems
10. Neck or back injury
23. Behavioral problems
11. Asthma or difficulty breathing
24. ADD / ADHD
12. Heart or blood pressure problems
25. Autism Spectrum Disorder
13. Chest pain with exercise
26. Other (please list below)
If you answer yes to any of the above, please explain:
Ongoing Medications
Name
Dosage
Frequency
Allergies – All Types (Foods, Medicines and Insect Bites)
Type
Reaction
Child and Youth Services Health Assessment / Sports Physical Statement
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