5141.31 - Health Examinations for Middle School Athletic Participation

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5141.31

Students

Health Examinations for Middle School Athletic Participation

All participants in middle/high school intramural and interscholastic sports must meet the following prerequisites:

A yearly physical examination is required. The proper school form (5141.31a & b) must be completed and returned to the school before the student may practice or play. If the student cannot, for economic or other important reasons, obtain an examination by his/her physician, the school doctor will provide the examination upon written request to the registered nurse at the student's school. The medical history must be filled out by the parent or guardian before the student will be seen by the physician. The student take the form to the doctor or nurse.

All sport participation physicals must be done AFTER May 1st of the upcoming school year.

The interscholastic sports permission form, which includes an important warning statement, must be filled out and signed by both parent or guardian and the prospective student athlete.
Emergency medical forms must also be filled out by the parent or guardian. These forms will enable the student athlete to receive medical attention for injury or illness that occurs while participating in school sponsored activities if the parent cannot be reached to give consent to emergency personnel.

Policy adopted: March 28, 2013 WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

5141.31

Form #1

WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

Individual Health History for Sports Candidates

PART I – Personal Health Information/Authorization

Student’s Name: _____________________________________ DOB: _____________________

School: ____________________ Grade: ___ Homeroom: _____ Name of Sport: ___________

Parent/Guardian to answer and sign below. Since last filling out form: Circle One

1. Has your child been told not to participate in any sport? No Yes

2. Has your child been unconscious or lost memory from a blow to the head? No Yes

3. Has your child had a joint injury/sprain or been on crutches? No Yes

4. Has your child had a major injury/fracture or dislocation? No Yes

5. Is your child under a physician’s care now? No Yes

6. Does your child take medication daily/routinely? No Yes

7. Has your child had an illness lasting longer than one week? No Yes

8. Does your child have allergies

(hay fever, hives, asthma, insects, medication)? No Yes

9. Has your child had heart trouble, heart murmur, high blood pressure,

persistent cough, chest pain, or other symptoms from strenuous exercise? No Yes

10. Has your child been hospitalized for an operation/illness? No Yes

11. Has your child been found to have but one of the paired organs

(i.e., one functioning, one removed, one absent - eye, ear, kidney etc.) No Yes

12. Do you have worries about your child’s health or other questions you

would like to discuss with the nurse, coach, doctor? No Yes

13. Female participants:

Absent or irregular monthly periods? No Yes

Disabling cramps with your menstrual periods No Yes

Explain all YES answers: _________________________________________________________

______________________________________________________________________________

5141.31

Form #1

(continued)

I/we give our permission for ________________________ to participate in organized high

school athletics, realizing that such activity involves the potential for injury which is inherent in

all sports. I/we acknowledge that even with the best coaching, use of appropriate equipment and

strict observance of the rules, injuries are still a possibility. On rare occasions these injuries can

be so severe as to result in total disability or even death.

I/we acknowledge that I/we have read and understand this warning.

Parent/Guardian ____________________________ Date _________________

Student/Player _____________________________

PART II – Athletic Emergency Information/Authorization

Student Name _______________________________________

Parent Name _______________________________________

Address _______________________________________

_______________________________________

Home Phone ___________________________ Business Phone – Mother ______________

Father ______________

Doctor _________________________________ Phone _____________________

Dentist _________________________________ Phone _____________________

Highly Allergic to _______________________________________________________________

Diabetic ___________________ Epileptic __________________ Other __________________

Asthma ___________________ Hospital Preference __________________________________

Medications ____________________________________________________________________

In the event parents cannot be reached, call:

Name: __________________________________________ Phone: _______________________

Insurance Company ______________________________________________________________

Policy Number __________________________________________________________________

Insurance Carrier _______________________________________________ (Parent or Guardian)

You have my permission to take whatever action is deemed necessary for the health and welfare

of my child.

Signature: ________________________________________ Date: ________________________

(Parent or Guardian)

Please Complete This Form an Return it to Your Nurse

5141.31

Form #2

WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

Parent/Guardian Permission for School Medical Advisor

to Administer Sports Health Assessment

Date _______________________

Dear Parent/Guardian,

You have indicated to the school nurse that you wish to have the school system complete your

child’s required health assessment. To accomplish this, please sign both the State of Connecticut

Health Assessment Record form and the permission slip below. This will allow the School

Medical Advisor or his/her designee to do the necessary physical assessment.

Sincerely,

______________________________

School Nurse

............................................................................................................................................................

My child, ___________________________ has my permission to have a physical by the School

Medical Advisor or his/her designee. I understand that the assessment may include a blood test

(hemoglobin). In addition, a blood pressure screening, TB skin test, and urine test will be

conducted.

_______________________________________ __________________

Parent/Guardian Date

Parents or Guardians are welcome and encouraged to be present during the physical assessment.

You will be notified of the date. If you cannot be present, you will be informed of any significant

findings.

5141.31

Form #3

WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

Report of Incident/Accident on

School Property or at School Activity

Please Check Injury: Student

Non-Student/Non-Employee

1. School or Department reporting incident: ____________________________________

2. Name of Injured: __________________________ Phone Number: _______________

3. Address: _______________________________________________________________

4. Date and Time of Incident: ________________________

month/day A.M. P.M.

5. Homeroom Teacher: _______________________ Grade: ____________________

6. Parent/Guardian: __________________________

7. If student accident, does student have school insurance? Yes No

8. Location of incident/accident: _____________________________________________

9. Nature of injury/medical problem: _________________________________________

________________________________________________________________________

10. Describe fully how incident/accident happened: _______________________________

________________________________________________________________________

11. Witnesses: ______________________________________________________________

12. Was injured taken to hospital/doctor? Yes No

13. How transported? _______________________________________________________

14. If YES, give name to hospital/doctor: _______________________________________

15. Describe treatment rendered by school personnel (indicate who administered): ____

________________________________________________________________________

16. Action taken to prevent similar incidents: ___________________________________

________________________________________________________________________

________________________________ _____________________________ _____________

Name of Person Completing Form/Position Principal’s Signature Date

5141.31

Form #4

WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

Athlete Injury and Return to Play Report Form

(From Treating Physician)

Date: __________________

School: Waterford High School

Clark Lane Middle School

Student’s Name: ___________________________ Sport: __________________________

Original Diagnosis: ____________________________________________________________

______________________________________________________________________________

Current Health Status: _________________________________________________________

______________________________________________________________________________

Follow up:

Must continue to see physician

May return to limited activities

May return to full activities including _______________________________________

________________________________________________________________________

Special Instructions: ___________________________________________________________

______________________________________________________________________________

________________________________ _____________________________ _____________

Physician’s Name Physician’s Signature Telephone #

This form is to be filed with Students Health Records

5141.31

Form #5

WINDSOR LOCKS PUBLIC SCHOOLS

Windsor Locks, Connecticut

ATHLETIC DEPARTMENT COACHES’ CHECKLIST

Date: __________________

Sport: ________________________________ Coach: __________________________

IMPORTANT INFORMATION: It is MANDATORY that a copy of this list be turned in to the Athletic Director or

the Assistant Athletic Director by NO later than THREE weeks prior to the first official practice date. It is your

responsibility to ensure that all aspects of the authorization for sports participation are carried out.

Authorization for Sports Participation

Student (Alphabetize by Grade)

Last First

Grade Parent’s

Permission

Phys.

Exam

Medical

Clearance

Medical

Information

Date of

Birth

Academic

Eligibility

5141.31

Form #6

SPORTS PHYSICAL HISTORY

Name Date of Birth

Male Female Grade

Parent/Guardian Name:

Home Phone #: Work Phone #:

Health History:

Date of last diphtheria – tetanus booster

Is child taking medication presently?

Does child have any allergies?

(medicine, bees, food, etc.)

Has child ever passed out or been dizzy during exercise?

Does child tire quicker than teammates during exercise?

Has any member or your family died of a heart attack or

sudden death before age 40?

Has child ever had racing of heart or skipped beats?

Does your child wear special pads or braces?

Has your child ever had? (please include dates)

Yes* No Yes* No

Eye injury

Seizure/convulsions

Pneumonia

Asthma/wheezing

Chest pain

High blood pressure

Mononucleosis

Anemia (low iron)

Blood clotting problem

Hepatitis

Ulcer

Hernia

Heat Stroke

Diabetes

Thyroid disease

Blood in urine

Head/neck injury

Loss of consciousness

Skin problem

Headache (frequent)

Dental braces

Sprain

Dislocation

Fracture

Hospitalization/Surgery: Date:

*If you answered “yes” to any of the questions on this page, please describe:

Parent/Guardian Signature:

Date:

5141.31

Form #6

(continued)

SPORTS SCREENING EXAM

Name:

Height :

Grade:

Weight:

Age:

Pulse:

Blood Pressure: Last DT:

Glasses/contact lenses: YES NO Vision Screening:

Sports Screening:

Normal

Head (injuries, deformities)

Eyes (PERL, FROM, discs, fundi)

Ears (TMs, deformities

Nose (patency, lesions, polyps)

Mouth (lesions, teeth)

Throat (lesions)

Neck (supple, masses, nodes, FROM)

Chest (lungs, clear, deformities)

Heart (NSR, murmur, rub)

Shoulder (FROM, deformities, click)

Elbow (reflex, FROM, deformity)

Wrist (deformity, FROM)

Hand (strength, deformity)

Abdomen (+BS, tenderness, megaly, mass)

Back (lesions, scoliosis, tenderness)

Knee (reflex, FROM, injury, pain)

Ankle (FROM, pain, injury, pain)

Foot (ingrown toenail, flat feet, athlete’s foot)

Skin (lesions, rashes)

GU Male (testes down, hernias, Tanner I, II, III, IV, V)

Female (I, II, III, IV, V)

Assessment:

Recommendations:

Clearance: (circle appropriate number)

1. No restrictions

2. Cleared after notification of coach, athletic trainer, physician

3. Clearance deferred until further evaluation by a physician

Sports Qualifications:

Baseball Basketball Soccer Cross-country

Track & Field Other

All of the Above

Physician’s Certificate:

I have examined . In my opinion it is safe for him/her to

participate in competitive athletics.

Physician’s Signature Date

5141.31

Form #7

Parent/Guardian Medical & Athletic Release Form

Parents/Guardians please note page 1 & 2 must be filled out by parent/guardian. If your child is going to

have a school sponsored sports physical, page 1 and 2 must be completed and brought to the appointment.

Name:

Homeroom Teacher:

Date of Birth:

Grade:

Phone:

Age:

Address:

Parent/Guardian Name:

Parent/Guardian Address:

Parent/Guardian

Place of Employment:

Medical Coverage:

Medical Coverage #:

Phone:

*******************************************************************************

I give my permission for to:

(Students Name)

1. be examined by the school physician YES NO

2. participate in

(Name of Sport(s))

3. be treated in emergency situations at any certified medical facility by a qualified physician.

(Note: If student has sustained an injury requiring medical care, whether sports related or not,

he/she is required to seek medical assessment and obtain a doctor’s note prior to resuming

sports.)

(Parent/Guardian Signature) (Parent/Guardian Signature) (Date)

*******************************************************************************

A. Parent/Guardian insurance coverage is primary. Sports insurance covers the balance up to the

policy limitations.

B. If there is no parent/guardian coverage then the sports insurance is primary and pays from the first

dollar.

C. Student insurance does not cover interscholastic sports claims.