Harrisville Central School

Harrisville Central School<= /o:p>

Athletic Health Screening Form

Name:_<= /span>_____________________________________DOB:___________Gender: M / F Grade:___________

List anticipated sport(s):__________________________________________________________________= ___

Medications: None /________________________________________________________________________

Allergies: None /____________________________= _______________________________________________

Primary Care Physician:_____________________________________________________= _________________

In case of emergency, which hospital would you prefer the student be transported to= ?_____________________

Have you had any of the following:	Yes	No=	Comment
Chronic/recurrent illnesses
Recent hospitalizations
Any surgeries
Passed out, been dizzy or had chest pain during or after exercise
Get tired more quickly than your friends do during exercise=
Felt your heart race or skip beats
High blood pressure or high cholesterol
A heart murmur
A relative died of heart problems or sudden death before age 50<= /span>
A severe viral infection such as mononucleosis, in the last month
Been denied or restricted in your participation in sports
A current skin problem (for example: rashes, warts, ringworm)
A head injury or concussion
Been knocked out, become unconscious or lost your memory
A seizure
Frequent or severe headaches
Numbness or tingling in your arms, hands, legs or feet
Heat stroke or heat exhaustion
Coughing, wheezing, or have trouble breathing during or after exercise
Asthma, seasonal allergies or bee/hornet allergy
Use any special protective devices that aren’t usually used for your sp= ort (for example: knee brace, s= pecial neck roll, foot orthotic, retainer for teeth)
Problems with your eyes or vision
Wear glasses, contacts or protective eyewear
A sprain, strain, joint dislocation or broken bone
Any other problems with pain or swelling in muscles, tendons, bones or joints
Desire to weigh more or less than you do now
Used supplements/vitamins to gain/lose weight or to improve performance
FEMALES ONLY:=
When did you first begin having menstrual periods?
When was your most recent menstrual period?
Do you have menstrual periods monthly?

The above information is current and correct to the best of = my knowledge. I give my child permission to have an athletic physical.&n= bsp; We understand clearly that the questions are asked in order to decid= e if this student is in a proper condition to participate in the athletic activi= ty named at the top of this form. The answers are correct as of the date this form is signed. All answers will be kept confident= ially in his/her health record in the school health office.=

Signature of athlete: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Date: &= nbsp; = .

Parent/Guardian Name (print= ): &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Phone: &= nbsp; &nbs= p; = .

Signature of parent/guardia= n: &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Date: &= nbsp; &nbs= p; &= nbsp; .<= o:p>