~Signature


Have you had infectious mononucleosis (mono) within the last month? Do you have any rashes, pressure sores or other skin problems? ~ave you had a herpes ...

PRE-PARTICIPATION PHYSICAL - CONSENT - INSURANCE Shaded headline areas are to be completed by student, parent/guardia"! or, 18-y~ar_-old There are FOUR (4) signatures on this page

· .- ·11;

to be completed by student, parenVguardian and/o r 18-year-old

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

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IIMr lifUSOC'ialilln

Student Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ _ ____ LAST

FIRST

MIDDLE INITIAL

StudentAddress: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ STREET

Gender:

0

M

0

F

ZIP

CITY

Age : _ _ Date of Birth : _ _ _ _ _ _ _ _ _ Place of Birth (City/S t a t e ) : - - - - - - - - - - - - - - - - - -

School: - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - Circle Grade:

6

7

8

9

10

11

12

Father/Guardian N a m e : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Phone (home): _ _ _ _ _ _ _ _ _ _ _ _ _ _ (work): _ _ _ _ _ _ _ _ _ _ _ _ _ (cell): - - - - - - - - - - - - - - -Mother/Guardian Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Phone (home): _ _ _ _ _ _ _ _ _ _ _ _ _ _ (work): _ _ _ _ _ _ _ _ _ _ _ _ _ (cell) : - - - - - - - - - - -- - - - -

.:

STUDENT PARTICIPATION & PARENT or GUARDIAN or 18-YEAR-OLD CONSENT: ·;-:-,;:

-

The information submitted herein is truthful to the best of my knowledge. By my/my child's signature below, 1/we acknowledge that 1/we have received concussion educational information that meets Michigan Department of Health and Human Services and MHSAA requirements .

- '.

:~-·:

· ..':~

0

Further, in consideration of my/my chi ld's participation in MHSAA-sponsored athletics, 1/we do hereby agree, understand , appreciate, and acknowledge: that participation in such athletics is purely voluntary; that such activities involve physical exertion and contact and that there is inherent risk of personal injury associated with participation in such activities, which risk 1/we assume; and that 1/we agree to , and hereby waive any and all claims, suits, losses, actions, or causes of action against the MHSAA, its members, officers, representatives, committee members, employees, agents, attorneys, insurers, volu nteers, and affiliates based on any injury to me, my child, or any person, whether beca use of inherent risk, accident, negligence, or otherwise, during or arising in any way from my/my child 's participation in an MHSAA-sponsored sport. 1/we understand that I am/we are expected to adhere firmly to all established athletic policies of my school district and the MHSAA. 1/we hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the MHSAA of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for interscholastic athletics. My child has my permission to accompany the team as a member on its out-of-town trips .

~ Signature of STUDENT: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date: - - - - - - -~ Signature of PARENT or GUARDIAN or 18-YEAR-OLD: - - - - - - - - - - - - - - - - - - - - - Date: _ _ _ _ _ _ __ Our son/daughter will comply with the specific insurance regulations of the school district. The student-athlete has health insurance: 0

YES

0

NO

If YES , Family Insurance Co : - - - - - - - - - -- - - - - - - Insurance ID #: - - - - - - - -- - - - - - - - - - - Additionally, I hereby state that, to the best of my knowledge , my answers to the medical history questions (see reverse) are complete and correct.

~ Signature of PARENT or GUARDIAN or 18-YEAR-OLD: - - - - - - - - - - - - - - - - -- - - - Date: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (DETAC H HERE IF NEEDED TO ACCO MPANY STUDE NT-ATHL ETE) - - - - - - - · - - - - - - - - - - - - - - - - - - - -

----------------~an 18-year-old, or the parent or guardian of , recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. 1do hereby consent in advance to such emergency care , including hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care .

~ Signature of PARENT or GUARDIAN or 18-YEAR-OLD:

Date : - - - - - - - -

MEDICAL HISTORY: Completed by Parent or Guardian or 18-Year-Oid Student Name: - - - -- - - - - -- - - - - -- - - - - - - - Date of Exam: _ _ _ _ _ _ _ _ _ _ __ Phone : _ _ _ _ _ _ _ _ _ _ _ _ ____

Family Doctor: -MEDICAL QUESTIONS

0 Anemia

0 Diabetes

0 Infections

N

Have you ever used an inhaler or taken asthma medicine? _ _ _ _ _ _ _ _ _ _~---+

Do you have any ongoing medical conditions? If so, please identify below: 0 Asthma

Y

Do you cough, wheeze or have difficulty breathing during or after exercise?

Has a doctor ever denied or restricted your participation in sports for any reason? 0 Other:

Is there anyone in your family who has asthma?

Have you ever spent the night in the hospital or have you ever had surgery?

Were you born without, or missing a kidney, eye, testicle (mates), spleen or any other organ? Do you have groin pain or a painful bulge_or hernia in the groin area?

' : I

Have you ever passed out or nea~y passed out DURING or AFTER exercise?

Have you had infectious mononucleosis (mono) within the last month? Do you have any rashes, pressure sores or other skin problems? ~ave

you had a herpes or MRSA skin infection?

Do you have headaches or get frequent muscle cramps when exercising? 1 - - - - " - - - - ' - - - - - - - - -0- H_e_a_ rt _in_fe_c_ tio_n_ o_ _,i'--ch_o_le_s_te_ro_l _ _ _ _~---t----J , Have you ever become ill while exercising in the heat? Do you or ~!l'eone in your family have sickle cell trait or disea~ _

t

_i:iave you had any problems with your eyes or vision or any eye injuries?

+-

Do you wear glasses or contact lenses? Do you wear protective eyewear such as !JOggles or a face sh_ie_ld_?_ _ _ _ _ _ __ Immunization History: Are you missing any recommended vaccines? Do you have any allergies?

+-

Have you ever had a head injury or concussion? Do you have any concerns that you would like to discuss with a doctor? Have you ever received a blow to the head that caused confusion, prolonged headache or memory problems?

1

Have you ever had numbness, tingling, weakness or inability to move your arms or legs after being hit or falling? Have you ever had an eating disorder?

1--~---~~--~-~~-------~---~--~~-----J-~ ~ID_o~y~o_u_w_o_rry~ ab_o_ut~y~o_ur_w_e~ig~h_t?______________________~ Are_rou trying to or has anyone recommended that you gain or lose weight? Are you on a special diet or do you avoid certain types of foods? -FEMALES ONLY (Optional)

Y

N

J!ave you ever had a menstrual period? How old were you when you had your first menstrual period? f

Do you have any history of juvenile a~tis or_con~ective tissue dis:ce..:.a~ se:.c?_ __ Have you ever had an x-ray for neck instability or atlantoax~ instabi!i!r (Down syndrome or dwarfism)?

How many periods have you had in the last 12 months?

t

CURRENT-YEAR PHYSICAL= GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

PHYSICAL EXAMINATION & MEDICAL CLEARANCE: Completed by MD, DO, PA or NP EXAMINATION: Height:

Weight:

0 Male 0 Female

BP:

Pulse:

MEDICAL

NORMAL

Appearance: Martan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/Ears/Nose/Throat: Pupils Equal Hearing Lymph nodes Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PM I) Pulses: Simultaneous femoral and radial pulses Lungs Abdomen I Genitourinary (males only) I Skin: HSV: Lesions suggestive of MRSA, tinea corporis

~u~lc

-

--

---

-

L

I

Corrected: 0 Y 0 N

L20/

NORMAL

MUSCULOSKELETAL

ABNORMAL

Neck

I

-

RETURN DIRECTLY TO PATIENT

Vision: R 20/

ABNORMAL I

-

-

Back Shoulder/Arm Elbow/Forearm WrisUHand/Fingers Hip/Thigh Knee Leg/Ankle FooUToes Functional Duck Walk

I

L

RECOMMENDATIONS: _ _~~-~-~--~--~~~-~~~~---~--~~~~~~~~~-~~~----1certify that I have examined the above student and recommend him/her as be ing able to compete in supervised athletic activities NOT crossed out below. BASEBALL- BASKETBALL - BOWLING - COM PETITIVE CHEER - CROSS COUNTRY- FOOTBALL- GOLF - GYMNASTICS -IC E HOCKEY LACROSSE- SKIING- SOCCER- SOFTBALL- SWIMMING/DIVING- TENNIS- TRACK & FIELD - VO LLEYBALL- WRESTLING

~Name of Examiner (prinVtype) :

Date: _ _ _ _ _ _ _ _ __ __

~Signature of Examiner: - - - - - - - - - - - - - - - - - - - - -

(Check One): 0

MD

0

DO

0

PA

0

NP

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - (DETACH HERE IF NEEDED TO ACCOMPANY STUDENT-ATHLETE) - - - -

Phone:l____j._ _ _ _ _ _ ____ IN EMERGENCY (1 ): - - - - - - - - - -- - - - - Home#: L__)_ _ _ _ _ _ _ _ _ _ Cell #: l____j_ _ _ _ _ _ __ IN EMERGENCY (2): - - - - - - - - - - - - - --

Home#: L__)

Cell#: l____j_ _ _ _ _ _ __

Drug Reactions: - - - - - - - - - -- - - - - - - - - - - Current Medications: - - - - - - - - - - - - - - - - - - - - - - - - - - A l l e r g i e s : - - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

FORM A: FEB·20-17

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