Khsaa Athletic Participation - Physical Examination Form - Consent And Release 2009

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KHSAA Form GE04 Part 1, Physician and Parental Permission, Rev. 4/09, page 1 of 4
KENTUCKY HIGH SCHOOL ATHLETIC ASSOCIATION
2280 Executive Drive, Lexington, Kentucky 40505
Athletic Participation/Physical Examination Form/Consent and Release
PART I - ATHLETE INFORMATION
(This part must be completed by the student)
Name (Last, First, Initial)
School Year
Home Address (Street, City, State, Zip):
Gender
Grade
School
Date of Birth:
Birth Place (County, State):
Attendance History
Grade
School Name
School Year
Varsity Play – (Yes/No)?
9
10
11
12
I am planning to participate in the following (circle all you might try to play):
Baseball
Basketball
Cross Country
Football
Golf
Soccer
Fast Pitch Softball
Swimming
Tennis
Track and Field
Volleyball
Wrestling
Cheerleading
Other
PART II - MEDICAL HISTORY
This part must be completed by parent and student and presented to the authorized health care provider before the physical.
CHECK THE APPROPRIATE RESPONSE TO EACH ITEM:........................................................................................................................YES NO
1. Have you ever been hospitalized? ..................................................................................................................................................
2. Have you ever had surgery of any kind (e.g., tonsillectomy). ..........................................................................................................
3. Are you presently taking any medications or pills? .........................................................................................................................
4. Do you have any allergies (medicine, bees, or other insects)?. .......................................................................................................
5. Have you ever passed out during exercise? ....................................................................................................................................
6. Have you ever been dizzy during or after exercise? ........................................................................................................................
7. Have you ever had chest pain during or after exercise?..................................................................................................................
8. Have you ever had high blood pressure? ........................................................................................................................................
9. Have you ever been told you have a heart murmur?.......................................................................................................................
10. Have you ever had racing of your heart? ........................................................................................................................................
11. Has anyone in your family died of heart problems before 50?. .......................................................................................................
12. Do you have any skin problems? (itching, rashes, acne) .................................................................................................................
13. Have you ever had a head injury? ..................................................................................................................................................
14. Have you ever been knocked out or unconscious? .........................................................................................................................
15. Have you ever had a seizure or suffer from epilepsy? ....................................................................................................................
16. Have you ever had a stinger, burner or pinched nerve? ..................................................................................................................
17. Have you ever had heat related problems? ....................................................................................................................................
18. Have you ever been dizzy or passed out in the heat?. ....................................................................................................................
19. Do you cough heavily, or breath heavily during activity? ...............................................................................................................
20. Do you use any special equipment (e.g., knee brace)?....................................................................................................................
21. Have you had any problems with your eyes or vision?....................................................................................................................
22. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones? ............
23. Are you missing one of any paired organs (e.g., eyes) ....................................................................................................................
24. Have you ever been diagnosed with any form of asthma? .............................................................................................................
25. Are you using an inhaler for asthma? .............................................................................................................................................
26. Are you diabetic? ...........................................................................................................................................................................
27. Do you administer insulin to yourself? ............................................................................................................................................
28. Are you presently using tobacco in any form? ................................................................................................................................
29. Do you have a history of sickle-cell anemia in your family?............................................................................................................
30. Have you had any other medical problems? ...................................................................................................................................
31. Have you had a medical problem or injury within the last year?.....................................................................................................
32. Can you swim? ...............................................................................................................................................................................
33. When was your last tetanus shot? ____________________________________________________________________________

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