LHSAA MEDICAL HISTORY EVALUATION

IMPORTANT: This form must be kept on file with the school and is subject to inspection by the LHSAA Rules Compliance Team.

PART 1: INFORMATION ( To be filled out by parent or guardian only)
Name:_____________________ Grade:___________ School:____________________________________
Sex: M    F               Age:_________ Home Telephone:__________________________ Sports:___________________
SSN:______________________ Address, City, State, Zip Code:_________________________________________________
Parent's Name:___________________________   Parent's Employer:___________________     Work Telephone:_________________
Insurance Company:_____________________________________ Policy #:______________ Family Doctor:__________________

PART 2: MEDICAL HISTORY (To be filled out by parent or guardian only)
Has or does this athlete:   Circle & explain all "yes" answers:
1. Have a medical problem or injury since his/her last evaluation?
     Ever not been allowed to participate in sports for a medical reason?  		 YES                    NO
YES                    NO
2. Ever been hospitalized?
     Ever had surgery?
     Have any missing organs? (eye, kidney, testicle, etc.) 		YES                    NO
YES                    NO
YES                    NO
3. Presently take any medication? YES                    NO
4. Have any allergies to medicine or insect bites? YES                    NO
5. Passed out during or after exercise?
     Been dizzy or passed out during or after exercise?
     Have chest pain during or after exercise?
     Tire more quickly than his/her friends during exercise?
     Have high blood pressure?
     Been told he/she has a heart murmur?
     Have racing of the heart or skipped hearbeats?
     Have a family member that dies of heart problems or sudden death before age 50?
YES                    NO
YES                    NO
YES                    NO
YES                    NO
YES                    NO
YES                    NO
YES                    NO
YES                    NO
6. Have any skin problems? YES                    NO
7. Ever had a head or neck injury?
     Ever been knocked out or unconscious?
     Ever had a seizure?
     Ever had a stinger, burner, or pinched nerve? 		YES                    NO
YES                    NO
YES                    NO
YES                    NO
8. Ever had heat cramps?
     Ever been dizzy or passed out in the heat? 		YES                    NO
YES                    NO
9. Have trouble with breathing or coughing during or after activity? YES                    NO
10. Use any special equipment? (pads, braces, neck rolls, eye guards, kidney belt, etc.) YES                    NO
11. Have any problems with vision?
       Wear glasses or contacts? 		YES                    NO
YES                    NO
12. Ever sprained/strained, dislocated, fractured or had repeated swelling of any bones
        or joints? 		YES                    NO
13. Have any medical problems listed below? (Please check off)
        High Blood Pressure              Rheumatic Fever                     Diabetes                  Hepatitis
       Mononucleosis                        Abnormal Bleeding                 Tuberculosis         Asthma
        Sickle Cell Disease/Trait      Other (list) _____________________________________ 		 
14. List dates for last: Tetanus Shot: _____________________           Measles Immunization: __________________________
15. Female athletes, list dates for: First menstrual period:_____________________        Last menstrual period:____________________
        Longest time between periods last year:______________________________________

Please explain all "yes" answers from above: _______________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________


PART 3: SIGNATURES
(You must answer these questions and sign for your child to be examined)
1. The information on the reverse is current and correct to the best of my knowledge. YES                    NO
2. I give my permission for my child to be examined for school-related activities. YES                    NO
3. If, in the judgement of a school represenative, the named student athlete needs care or
     treatment as a result of injury or sickness, I do hereby request, consent, and authorize
     for such care as may be deemed necessary. 		YES                    NO
4. I recognize the evaluation to be done on my child is a standard pre-participation screening
     examiniation, and that no in-depth testing, x-rays, or cardiac testing will be performed. 		YES                    NO
5. I understand that if the medical staus of my child changes in any significant manner after
     his/her physical examination, I will notify his/her principal of the change immediately. 		YES                    NO
6. I give my permission for the athletic trainer to release information concerning my child's
     injuries to the head coach / athletic director / principal of his/her school. 		YES                    NO
         
Signature of Parent/Guardian: _______________________________________ Date:______________________
         
Signature of Student Athlete: ________________________________________ Date:______________________
         
PART 4: PHYSICAL
(To be filled out by a licensed physician/licensed nurse pracitioner in collaboration with doctor or a licensed
physician's assistant under the supervision of a licensed physician.)
Height:_________           Weight:__________            Blood Pressure:________________              Pulse: ______________
SYSTEM                                 NORMAL  ABNORMAL INITIALS COMMENTS
Heart    
Lung    
Other    


Abdominal
Genitalia
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Eye            Right    20/                          Left    20/                          Corrected?          YES                 NO
CLEARANCE: __________ A. Cleared    
                          __________ B. Cleared after further evaluation/treatment  
                                  ____________   C. Not cleared for: ____________ Collision       ____________ Contact        ____________ Non-contact


RECOMMENDATIONS:___________________________________________________________________________

_____________________________________________________________________________________________
NAME OF MD/NURSE PRACTITIONER: _____________________________ DATE:____________________
ADDRESS: The Pediatric Clinic, 888 Tara Boulevard, Baton Rouge, Louisiana, 70806 TELEPHONE: 225-926-4400
         
SIGNATURE OF MD/NURSE PRACTITIONER:____________________________________________________