Athletic Health History

To Be Completed By Parent

 

School Name ______________________Athlete’s Name ______________________________Date of Birth __/__/__ Grade____

Has your child ever had: (please check)

	YES	NO		YES	NO
Allergies/ Hay Fever			Elevated Blood Pressure
Bee Sting Allergy			Headaches
Asthma			Head Injury/Concussion
Anemia			Heart Problem; Murmur-Chest Pains
Arthritis			Nose Bleeds/Frequent or Severe
Bladder/Kidney Problem/Injury`			Ankle Injury
Convulsion/Seizures			Back Pain/Injury
Fainting Spells			Fracture-Dislocation Bones/Joints
Diabetes			Knee Pain/Injury
Ear Problems/Hearing Loss			Neck Injury
Eye Problems/Vision Loss			Nose Fracture
Injury to the spleen			Rheumatic Fever
Joint Sprain/Ligament tear, Muscle Pull			Stomach Ulcer
Is your child assigned to the Adaptive Physical Education Program, or has he/she ever been in an Adaptive Physical Education Program?			Has your child ever been unconscious or lost memory from a blow to the head?

Does your child have any of the following: (please circle)

Does your child have one eye or Severe Uncorrectable loss of vision in one or both eyes?     YES          NO

Does your child have severe hearing loss in both ears?     YES          NO

Does your child have one kidney?     YES          NO

Does your child have one Testicle?     YES          NO

Has your child ever had an illness, condition, or injury that required him/her to go to the hospital, either as an overnight patient or in the emergency room for x-rays?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Is your child under medical care now?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Is your child taking any medication now?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Has your child ever fainted during exercise?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Has there ever been a sudden death in a family member under 50 years of age?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Do you have any worries about your child’s health or other questions you would like to discuss with a Doctor?     YES          NO

Does your child have orthodontic appliances?     YES          NO

Does your child have capped teeth?     YES          NO

Does your child wear contact lenses for sports?     YES          NO

Does your child wear glasses for sports?     YES          NO

Since your child’s last physical examination, has he/she had any injury or medical illness?     YES          NO

If Yes, Explain: ________________________________________________________________________________

Circle all sports in which you give your child permission to participate in:

Fall Sports		Winter Sports		Spring Sports
Football	Boys Soccer	Skiing	Basketball	Softball	Baseball
Field Hockey	Cross Country	Ice Hockey	Track	Track	Boys Tennis
Volleyball	Girls Tennis	Wrestling	Gymnastics	Golf
Cheerleading	Twirling	Bowling	Cheerleading
Girls Soccer

 

Indigenous to athletics is the possibility of minor injury, and in the extreme, severe injury and even death. It is understood that Carmel School District will provide proper equipment and training, as well as safe facilities, in order to minimize these risks. Be my signature below, I agree to let the coach and/or administration administer proper first aid, contact emergency medical services if deemed necessary, and to contact me at the earliest opportunity.

 

Parent Signature ___________________________________________                      Date ___/___/___