Diaa Physical Form – Fill Out and Use This PDF

This physical evaluation must be completed after April 1 of the current year. It runs through June 30 of the following year.

Fill in Athlete, Phone, School, Age, Gender, Date of Birth, Grade and Parent/Guardian Name (Please Print).

Under PARENT/GUARDIAN CONSENTS, write the Name of Athlete who has your permission to participate in all interscholastic sports not checked.

If you check any sport in this box it means the athlete will not be permitted to participate in that sport.

Consent 1: your permission extends to all interscholastic activities whether conducted on or off school premises. You have read and discussed the list of items that protect against the loss of athletic eligibility, with said participant and you will retain that page for your reference. You waive any claim for injury or damage incurred by said participant while participating in the activities not checked.

Consent 2: to enable DIAA and its full and associate member schools to determine whether herein named student is eligible to participate in interscholastic athletics, you consent to the release of any and all portions of school record files, beginning with the sixth grade, including but not limited to, birth and age records, name and residence of student's parent(s), guardian(s) or Relative Care Giver, residence of student, health records, academic work completed, grades received and attendance records.

Consent 3: you further consent to DIAA's and its full and associate member schools use of the named student's name, likeness, and athletically related information in reports of interscholastic practices, scrimmages or contests, promotional literature of the Association, and other materials and releases related to interscholastic athletics.

Consent 4: by this signature, you consent to allow the physician(s) and other health care providers(s) selected by you or the schools to perform a pre-participation examination on your child and to provide treatment for any injury received while participating in or training for athletics for his/her school.

Sign on each Parent Signature line and enter the Date after each consent.

Note: This form is to be filled out by the patient and parent prior to seeing the physician.

On the HISTORY FORM, fill in Date of Exam, Name, Date of birth, Sex, Age, Grade, School and Sport(s).

Mark Yes or No under the general questions, medical questions, heart health questions about you, heart health questions about your family and bone and joint questions. For females only, also fill in the questions about menstrual periods, how old you were when you had your first menstrual period and how many periods you have had in the last 12 months.

Explain “Yes” answers in Explain “yes” answers here. Circle questions you don't know the answers to.

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking.

Mark Yes or No for Do you have any allergies? If yes, please identify the allergy: Medicines, Pollens, Food or Stinging Insects.

For "I hereby state that, to the best of my knowledge, my answers to the questions are complete and correct", sign on the Signature of athlete and the Signature of parent/guardian and enter the Date.

The Health Care Provider signs under: I have examined the named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined.

The health care provider marks Cleared for all sports without restriction; Cleared for all sports without restriction with recommendations for further evaluation or treatment for; Not cleared; or Pending further evaluation, for any sports or for certain sports, with the Reason and the Recommendations.

The health care provider prints or types the Name of Health Care Provider, the Date, the Address and the Phone, and signs on the Signature of Health Care Provider MD, DO, PA or NP.

A copy of the physical exam can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

School Athlete Medical Card (Parent/Guardian: please print and complete Sections 1, 2 & 3).

Section 1: Contact/Personal Information. Fill in the name, sport(s), age, grade, birth date, guardian name, address and the phone lines (H), (W), (C) and (P), the other authorized person to contact in case of emergency, and the Preference of Physician (and permission to contact if needed) with hospital preference, insurance, policy # and group.

Section 2: Medical Information. Fill in medical illnesses, last tetanus (mo/yr), allergies, medications (any medications that may be taken during competition require a physician's note), previous head/neck/back injury, previous heat-related problems, previous significant injuries and any other important medical information.

Section 3: Consent for Athletic Conditioning, Training and Health Care Procedures. In the event I cannot be reached in an emergency I give permission for my child to be transported to receive necessary treatment. The Parent/Guardian Signature and Date and the Athlete's Signature and Date go at the end of the consent.

Section 4: Clearance for Participation. The health care provider marks Cleared without restrictions or Cleared with the following restrictions, then signs on Health Care Provider's Signature as MD/DO, PA,NP with the Date.

Note: If any changes occur, a new card should be completed by the parent/guardian. This card contains personal medical information and should be treated as confidential by the school, its employees, agents, and contractors.