ࡱ> `b_y OlbjbjEE 8n''G22uuuuu<.|||JEu||uu.uu% {0t/Fttu|Z@4J|||u|||t|||||||||2 ;:  DARIEN PUBLIC SCHOOLS SPORTS PARTICIPATION HEALTH RECORD This evaluation is to determine readiness for sports participation only. It should not be used as a substitute for regular health maintenance examinations. THIS SIDE MUST BE COMPLETED BY PARENT AND STUDENT BEFORE BEING BROUGHT TO THE DOCTORS OFFICE. Name ________________________________________ Age _______ Sex ______ Grade ______ Phone ______________________ Address ________________________________________ Fall Sport __________ Winter Sport __________ Spring Sport __________ MEDICAL HISTORY (to be completed by parent or guardian) 1. Do you have any allergies? (food, drugs, insect stings, etc.) YES ____ NO ____ List: ___________________________________________________________________________ 2. Are you currently taking any drugs or medications including steroids or protein supplements? (daily or occasionally) YES ____ NO ____ List: ___________________________________________________________________________ 3. Are you presently being treated for any condition by a physician or other health care professional? YES ____ NO ____ Explain: _________________________________________________________________________ 4. Have you ever been advised by a doctor not to participate in any sport? YES ____ NO ____ Explain: __________________________________________________________________________ 5. Do you have any chronic conditions, disorders or diseases? YES ____ NO ____ if yes, check those applicable: Asthma ____ Bleeding Disorders ____ Diabetes ____ Epilepsy (seizures) ____ Hepatitis (liver disease) ____ Sickle Cell Anemia ____ Hypertension (high blood pressure) ____ Mononucleosis ____ year ______ Kawasakis Disease ____ Handicap (describe) __________________________________ Other _____________________________________ Please check where applicable if you have or have had any of the following: YES NO YES NO ____ ____ Head injury, concussion, or been unconscious Eye injury or retinal detachment ____ ____ If yes, how many times _________ Blurred vision or vision in one eye only ____ ____ ____ ____ Headaches more than once a week Wear glasses or contact lenses ____ ____ ____ ____ Lack of feeling or numbness in any part of the body Hearing loss or impairment in one or both ears ____ ____ ____ ____ Heat exhaustion or heat stroke Tubes in ears or a perforated eardrum ____ ____ ____ ____ Difficulty running mile without stopping False teeth, caps or braces ____ ____ ____ ____ Chest pain, dizziness or passing out during exercise Nose bleeds for no reason ____ ____ ____ ____ Coughing, wheezing or gasping for breath with Bruising easily or taking a long time to stop ____ ____ exercise or cold weather bleeding when cut ____ ____ Smoke cigarettes or chew tobacco Diarrhea more than once a week ____ ____ ____ ____ Heart problem, murmur or arrhythmia Black or bloody bowel movements (stools) ____ ____ ____ ____ Family member with a heart attack under age 50 Kidney disease or dark, brown or bloody urine ____ ____ ____ ____ Loss or gain of more than 10 lbs. in last year Less than 2 kidneys or, in males, 2 testicles ____ ____ ____ ____ Special diet for medical reasons Lump(s) in armpit or groin ____ ____ For female participants: Rash or skin problem ____ ____ ____ ____ Absent or irregular monthly periods Neck or spine or low back injury or pain ____ ____ ____ ____ Disabling cramps with your menstrual periods Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any of the following bones, joints or muscles? % Head % Neck % Shoulder % Elbow % Forearm % Wrist % Hand % Chest % Ankle % Foot % Back % Hip % Thigh % Knee % Shin / Calf Please describe all items checked above including the year the injury occurred: ____________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ STUDENT AND PARENT OR GUARDIAN: We hereby state that we have reviewed this medical history and found the information supplied above to be correct to the best of our knowledge. _______________________________________ _____________________ __________________________________ Student Signature Date Parent or Guardian Signature MEDICAL EXAMINATION (to be completed by Medical Doctor or his/her designee) _____________________________________ _____/_____/_____ has had a complete history and physical exam on ____/____/____ HEIGHT ____________ WEIGHT ____________ BLOOD PRESSURE ____________________ HCT/HGB PULSE ____________ URINALYSIS __________ protein _____ blood _____ glucose _____ VISUAL ACUITY: right ______________ left ______________ Corrected to right ______________ left ______________ HEARING ___________________________________________ LAST TETANUS BOOSTER __________________________ LAST MEASLES (MMR) BOOSTER __________________________ OTHER IMMUNIZATIONS __________________________ BODY FAT (optional) __________________________ CHOLESTEROL (optional) __________________________Students Name Birth Date NormalAbnormal FindingsAppearanceSkinHEENTRespiratoryCardiovascular Arrhythmia MurmurAbdomenSpineNeurologicalGenitalia (hernia)Physical Maturity (Tanner Stage) 1 2 3 4 5 SUMMARY:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ORTHOPEDIC EXAM MUSCULO-SKELETAL EVALUATION to include range of motion, strength, flexibility Normal Abnormal FindingsNeckSpineShouldersArms / HandsHipsThighsKneesAnklesFeet RECOMMENDATIONS Weight Loss / Gain __________________________ Medications ___________________________ Strengthening __________________________ Special Equipment __________________________ Stretching __________________________ Bracing / Taping ___________________________ Conditioning (Endurance) __________________________ I certify that on this date, on the basis of the examination requested by the school authorities and the students medical history as furnished to me, I have found no reason which would make it medically inadvisable for this student to compete in supervised athletic activities except: _____________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ______________________________, M.D. _______________ ____________________ ____________________________ Signature of Medical Doctor Date ;<N~8 : Z ] p r z { " 1 2 Z vhZhh CJOJQJ^JaJh`CJOJQJ^JaJhp(rCJOJQJ^JaJhp(r5CJOJQJ^JaJ#hp(rhp(r5CJOJQJ^JaJhp(rCJOJQJ^JaJhzCJOJQJ^JaJ hp(rhp(rCJOJQJ^JaJh@CJOJQJ^JaJhp(rOJQJ^Jhp(rhp(r5OJQJ^Jhp(rh;<9 : ! 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