Office Use Only

School Physician Signature ________________________________ School Nurse Signature ________________________________

Date Cleared ________________

Date of Last Sports Physical _______________

Scotia-Glenville C.S.D.

Interval Health History Form for Sports Participation

Prior to the start of tryout sessions or practice at the beginning of each season, a health history review for each student must be completed and turned in to the health office.

Part A- TO BE COMPLETED BY THE STUDENT

Student Name_________________________ Date of Birth_____________

Grade_______________ Age____________________

Sport________________________________ Modified JV/Varsity (Please circle one)

Part B-TO BE COMPLETED BY THE PARENT OR GUARDIAN

NOTE: “YES” to any of these questions does not mean automatic disqualification from participation in sports. However, it will require a review and approval by the school physician before the student can report to practice or tryouts.

HISTORY SINCE LAST HEALTH APPRAISAL

If the answer to any of the following questions is “YES,” please describe the condition or situation that prompted your answer, giving the date and doctor clearance in Part C.

1. Any injuries requiring medical attention including,

concussion or loss of consciousness? YES NO DATE______

2. Any illness lasting more than 5 days? YES NO DATE______

3. Currently taking medication or under the care

of a physician for an active problem? YES NO DATE______

4. Any feelings of faintness, dizziness, fatigue,

or chest pain after exercise or exertion? YES NO DATE______

5. Change in wearing glasses or contact lenses? YES NO DATE______

6. Any fractures or surgical procedures? YES NO DATE______

7. Any treatment in a hospital or emergency room? YES NO DATE______

8. Developed any allergies, asthma exercise induced

asthma or reactions to medication? YES NO DATE______

9. Any chronic disease? (Diabetes, bleeding disorder

Seizures?) YES NO DATE______

10. Problems with heat exhaustion/heat fatigue? YES NO DATE______

11. Absence of or the significant impairment of one of

a pair of organs? (kidney, eye, ear, testicle) YES NO DATE______

12. Any history of sudden death in a family member

under the age of 50? YES NO DATE______

PART C- TO BE COMPLETED BY PARENT OR GUARDIAN

Describe the condition or situation that caused you to answer “YES” to any question in PART B. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PART D-PARENTAL PERMISSION

I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate in the athletic sport named in PART A of this form. The answers are correct as of this date and he/she has my permission to participate.

SIGNED___________________________________ DATE_____________