NEWHANOVERCOUNTYSCHOOLSPRE-PARTICIPATIONSPORTSSCREENING

(IN ACCORDANCEWITHNORTH CAROLINAHIGHSCHOOLATHLETICASSOCIATION GUIDELINES)

Student’sName:

DateofBirth:

Grade:

Address:

Phone:

School:

PersonalPhysician:

Sex:

Age:

Sports:

Incaseofemergency,contact:

Phone:

Relationship:

Thisisa screeningexaminationforparticipationinsports.Thisdoesnot substitutefora comprehensiveexaminationwithyourchild’sregular physicianwhere important preventive healthinformationcan be covered.

ParentsStudents,pleasereviewallquestionsandanswerthemto thebestof yourknowledge. If you do not understand or don’t know the answer to a question please ask your doctor.Notdisclosing accurateinformationmayputthestudentatriskduring sports activity.Pleaseexplain“Yes”answersbelow.Physicians,werecommendcarefullyreviewingthesequestionsandclarifyinganypositiveanswers. / Yes / No / Don’tknow
1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, etc.]?
List: /  /  / 
2.Istheathletepresentlytakinganymedicationsorpills? /  /  / 
3.Does theathletehaveanyallergies(medicine,beesorotherstinginginsects,latex)? /  /  / 
4.Does the athlete have the sickle cell trait? /  /  / 
5. Has theathleteeverhad a head injury, been knocked out, or had a concussion? /  /  / 
6. Has theathleteever had a heat injury (heat stroke) or severe muscle cramps with activities? /  /  / 
7. Has theathleteeverpassed out or nearly passed outDURINGexercise, emotion, or startle /  /  / 
8. Has the athlete ever fainted or passed out AFTER exercise? /  /  / 
9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)? /  /  / 
10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise?
Hasadoctorevertoldtheathletethattheyhaveaheartinfection? /  /  / 
11. Has theathlete everbeendiagnosedwithexercise-induced asthma? /  /  / 
12. Has a doctor ever told the athlete that they have high blood pressure? /  /  / 
13. Has a doctor ever told the athlete that they have a heart infection?
Hastheathleteeverhadaheadinjury,beenknockedout,orhadaconcussion? /  /  / 
14. HasadoctoreverorderedanEKG orothertestforthe athlete’sheart, orhasthe athleteeverbeentoldthey haveamurmur? /  /  / 
15. Hastheathleteeverhaddiscomfort,pain,orpressureinhischestduring orafterexerciseorcomplained oftheir heart “racing”or“skipping beats? /  /  / 
16. Has the athlete ever has a seizure or been diagnosed with an unexplained seizure problem?
Hastheathleteeverhadaheat injury (heatstroke)orsevere musclecramps withactivities? /  /  / 
17. Has the athlete ever had a stinger, burner, or pinched nerve? /  /  / 
18. Hastheathleteeverhad anyproblemswiththeireyesorvision? /  /  / 
19. Hastheathleteeversprained/strained,dislocated,fractured,brokenorhadrepeatedswelling orotherinjuryofanybonesorjoints? /  /  / 
Head / Shoulder / Thigh / Neck / Elbow / Knee / Chest / Hip
Forearm / Shin/Calf / Back / Wrist / Ankle / Hand / Foot
20. Hastheathleteeverhadaneating disorder, ordoyouhaveanyconcernsaboutyoureatinghabitsorweight? /  /  / 
21. Has the athlete ever been hospitalized or had surgery?
Does theathletehaveanychronicmedicalillnesses(diabetes,asthma,kidneyproblems,etc.)? /  /  / 
22. Hastheathletehadamedical problemorinjury sincetheirlastevaluation? /  /  / 
FAMILYHISTORY
23. Hasanyfamilymemberhadasudden,unexpecteddeathbeforeage50(includingfromsuddeninfantdeathsyndrome,caraccident,drowning)? /  /  / 
24. Hasanyfamilymemberhadunexplainedheartattacks,faintingorseizures? /  /  / 
25. Does theathlete haveafather, motherorbrotherwithsicklecell disease? /  /  / 

Elaborate onany positive (yes) answers:

By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is correct to

the best of my knowledge. Furthermore, as a parent or legal custodian,I givepermission formychildto participateinsports.

Signatureofparent/legalcustodian:

Date:

SignatureofAthlete:

Date:

Phone#:

(over)

NEWHANOVERCOUNTYSCHOOLSPRE-PARTICIPATIONSPORTSSCREENING

(Mustbecompletedbya LicensedPhysician,NursePractitionerorPhysician’sAssistant)

Student’sName: School:

DateofBirth:

Height

Weight

BP /

BP /

Pulse

VisionR20/

L20/

Corrected:YesNo

THESEAREREQUIREDELEMENTSFORALLEXAMINATIONS

NORMAL / ABNORMAL / ABNORMALFINDINGS
PULSES
HEART
LUNGS
SKIN
NECK/BACK
SHOULDER
KNEE
ANKLE/FOOT
OtherOrthopedicProblems

OptionalExaminationElements–shouldbedoneifhistoryindicates

HEENT
ABDOMINAL
GENITALIA(MALES)
HERNIA(MALES)

Clearance:

A.Cleared

B.Clearedaftercompletingevaluation/rehabilitationfor: ______

C.***Medical Waiver Form Must be attached (for the condition of: ______)

D.Notclearedfor:CollisionContact

Non-contact: StrenuousModeratelystrenuous Non-strenuous

Dueto:

AdditionalRecommendations/RehabInstructions:_

NameofPhysician/Extender:

SignatureofPhysician/Extender:

MDDOPANP

(Signature and circleofdesignateddegreerequired)

DateofExam:

PhysicianOfficeStamp:

Address:

Phone:

***The followingare considereddisqualifyinguntil appropriatemedical andparentalreleasesare obtained: post-operativeclearance,acute infections, obviousgrowth retardation, diabetes, jaundice,severe visual orauditory impairment,pulmonary insufficiency,organic heart disease or hypertension, enlarged liveror spleen, a chronic musculoskeletal conditionthatlimitsabilityfor safe exercise/sport (i.e. Klippel-Feil anomaly,Sprengel’sdeformity),historyof convulsions or concussions,absence of/ orone kidney,eye,testicle orovary,etc. This formapprovedbythe NCHSAASports MedicineAdvisoryCommitteeApril 2013,and thenmodifiedbyNHCSAugust 2013.