DELAWARE INTERSCHOLASTIC ATHLETIC ASSOCIATION
Parents/Guardian: The DIAA pre-participation physical evaluation and consents form is a five page document. Pages one, two and four require your signature while page five is a reference for you to keep. This physical evaluation must be completed after April 1 of the current year playing sports and runs through June 30 of the following year.
Athlete: _________________ Phone: ___________ School: _____________
Age:________ |
Gender: ________ |
Date of Birth: _________ |
Grade: ______ |
Parent/Guardian Name: (Please Print) |
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PARENT/GUARDIAN CONSENTS
________________________ Has my permission to participate in all interscholastic
(Name of Athlete) |
sports not checked below. |
If you check any sport in this box it means the athlete will not be permitted to participate in that sport.
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Collision |
Contact |
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Non-Contact |
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__ football |
_ ice hockey |
__ volleyball |
___ softball |
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cross country |
___tennis |
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__ soccer |
_ boys’ lacrosse |
__ field hockey |
___ baseball |
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swimming |
___golf |
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__ wrestling |
__ basketball |
___ girls lacrosse |
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track |
___crew |
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__ squash |
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__ cheerleading |
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1.My permission extends to all interscholastic activities whether conducted on or off school premises. I have read and discussed the list of items that protect against the loss of athletic eligibility, with said participant and I will retain that page for my reference. I have also discussed with him/her and we understand that physical injury, including paralysis, coma or death can occur as a result of participation in interscholastic athletics. I waive any claim for injury or damage
incurred by said participant while participating in the activities not checked above. Parent Signature: _____________________________ Date: ___________________
2.To enable DIAA and its full and associate member schools to determine whether herein named student is eligible to participate in interscholastic athletics, I hereby consent to the release of any and all portions of school record files, beginning with the sixth grade, of the herein named student, 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.
Parent Signature: _____________________________ Date: ___________________
3.I further consent to DIAA’s and its full and associate member schools use of the herein 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.
Parent Signature: _____________________________ Date: ___________________
4.By this signature, I hereby consent to allow the physician(s) and other health care providers(s) selected by myself or the schools to perform a pre-participation examination on my child and to provide treatment for any injury received while participating in or training for athletics for his/her school. I further consent to allow said physician(s) or health care provider(s) to share appropriate information concerning my child that is relevant to participation, with coaches, medical staff, Delaware Interscholastic Athletic Association, and other school personnel as deemed necessary. Such information maybe used for injury surveillance purposes.
Parent Signature: _____________________________ |
Date:__________________ |
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■PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician.)
Date of Exam ___________________________________________________________________________________________________________________
Name __________________________________________________________________________________ Date of birth __________________________
Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies? |
Yes No If yes, please identify speciic allergy below. |
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Medicines |
Pollens |
Food |
Stinging Insects |
Explain “Yes” answers below. Circle questions you don’t know the answers to.
1.Has a doctor ever denied or restricted your participation in sports for any reason?
2.Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections Other: _______________________________________________
3.Have you ever spent the night in the hospital?
4.Have you ever had surgery?
HEART HEALTH QUESTIONS ABOUT YOU |
YES |
NO |
5.Have you ever passed out or nearly passed out DURING or AFTER exercise?
6.Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
7.Does your heart ever race or skip beats (irregular beats) during exercise?
8.Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure |
A heart murmur |
High cholesterol |
A heart infection |
Kawasaki disease |
Other: _____________________ |
9.Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
10.Do you get lightheaded or feel more short of breath than expected during exercise?
11.Have you ever had an unexplained seizure?
12.Do you get more tired or short of breath more quickly than your friends during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY |
YES |
NO |
13.Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?
14.Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
15.Does anyone in your family have a heart problem, pacemaker, or implanted deibrillator?
16.Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
BONE AND JOINT QUESTIONS |
YES |
NO |
17.Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
18.Have you ever had any broken or fractured bones or dislocated joints?
19.Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
20.Have you ever had a stress fracture?
21.Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarism)
22.Do you regularly use a brace, orthotics, or other assistive device?
23.Do you have a bone, muscle, or joint injury that bothers you?
24.Do any of your joints become painful, swollen, feel warm, or look red?
25.Do you have any history of juvenile arthritis or connective tissue disease?
26.Do you cough, wheeze, or have dificulty breathing during or after exercise?
27.Have you ever used an inhaler or taken asthma medicine?
28.Is there anyone in your family who has asthma?
29.Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
30.Do you have groin pain or a painful bulge or hernia in the groin area?
31.Have you had infectious mononucleosis (mono) within the last month?
32.Do you have any rashes, pressure sores, or other skin problems?
33.Have you had a herpes or MRSA skin infection?
34.Have you ever had a head injury or concussion?
35.Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
36.Do you have a history of seizure disorder?
37.Do you have headaches with exercise?
38.Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
39.Have you ever been unable to move your arms or legs after being hit or falling?
40.Have you ever become ill while exercising in the heat?
41.Do you get frequent muscle cramps when exercising?
42.Do you or someone in your family have sickle cell trait or disease?
43.Have you had any problems with your eyes or vision?
44.Have you had any eye injuries?
45.Do you wear glasses or contact lenses?
46.Do you wear protective eyewear, such as goggles or a face shield?
47.Do you worry about your weight?
48.Are you trying to or has anyone recommended that you gain or lose weight?
49.Are you on a special diet or do you avoid certain types of foods?
50.Have you ever had an eating disorder?
51.Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY
52.Have you ever had a menstrual period?
53.How old were you when you had your irst menstrual period?
54.How many periods have you had in the last 12 months?
Explain “yes” answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete __________________________________________ Signature of parent/guardian ____________________________________________________________ Date _____________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
■PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name __________________________________________________________________________________ Date of birth __________________________
PHYSICIAN REMINDERS
1.Consider additional questions on more sensitive issues
•Do you feel stressed out or under a lot of pressure?
•Do you ever feel sad, hopeless, depressed, or anxious?
•Do you feel safe at your home or residence?
•Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
•During the past 30 days, did you use chewing tobacco, snuff, or dip?
•Do you drink alcohol or use any other drugs?
•Have you ever taken anabolic steroids or used any other performance supplement?
•Have you ever taken any supplements to help you gain or lose weight or improve your performance?
•Do you wear a seat belt, use a helmet, and use condoms?
2.Consider reviewing questions on cardiovascular symptoms (questions 5–14).
EXAMINATION
Height |
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Weight |
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Male Female |
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BP |
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Pulse |
Vision R 20/ |
L 20/ |
Corrected Y N |
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MEDICAL |
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NORMAL |
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ABNORMAL FINDINGS |
Appearance
•Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insuficiency)
Eyes/ears/nose/throat
•Pupils equal
•Hearing
Lymph nodes
Heart a
•Murmurs (auscultation standing, supine, +/- Valsalva)
•Location of point of maximal impulse (PMI)
Pulses
•Simultaneous femoral and radial pulses Lungs
Abdomen
Genitourinary (males only)b
Skin
•HSV, lesions suggestive of MRSA, tinea corporis Neurologic c
MUSCULOSKELETAL Neck
Back Shoulder/arm Elbow/forearm Wrist/hand/ingers Hip/thigh
Knee Leg/ankle Foot/toes
Functional
• Duck-walk, single leg hop
aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. bConsider GU exam if in private setting. Having third party present is recommended.
cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of signiicant concussion.
Cleared for all sports without restriction
Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________________
____________________________________________________________________________________________________________________________________________
Not cleared
Pending further evaluation For any sports
For certain sports _____________________________________________________________________________________________________________________
Reason ___________________________________________________________________________________________________________________________
Recommendations _________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
I have examined the above-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 above. A copy of the physical exam is on record in my ofice and can be made available to the school at the request of the parents. If condi- tions 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).
Name of Health Care Provider (Print/type) _____________________________________________________________________________________________________ Date ________________
Address ___________________________________________________________________________________________________________ Phone _________________________
Signature of Health Care Provider _______________________________________________________________________________________________________________________, MD, DO, PA or NP
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
SCHOOL ATHLETE MEDICAL CARD
(Parent/Guardian: please print and complete Sections 1, 2 & 3)
Section 1: CONTACT/PERSONAL INFORMATION
NAME:____________________________________________ SPORT(S):______________________________
AGE:____GRADE:____ BIRTH DATE:___________ GUARDIAN NAME:__________________________________
ADDRESS:______________________________________________________________________________________
PHONE: (H)_____________________ (W)_________________ (C)_________________ (P)_________________
Other authorized person to contact in case of emergency:
NAME:__________________________________________ PHONE(s):______________________________________
NAME:__________________________________________ PHONE(s):______________________________________
Preference of Physician (and permission to contact if needed):
NAME:___________________________________________________ PHONE:_____________________________
HOSPITAL PREFERENCE:______________________ INSURANCE:_____________________________________
POLICY #:________________________ GROUP:_________________________ PHONE:____________________
Section 2: MEDICAL INFORMATION
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:__________________________________________________________________
ANY OTHER IMPORTANT MEDICAL INFORMATION:__________________________________________________
Section 3: Consent for Athletic Conditioning, Training and Health Care Procedures
I hereby give consent for my child to participate in the school’s athletic conditioning and training program, and to receive any necessary healthcare treatment including first aid, diagnostic procedures, and medical treatment, that may be provided by the treating physicians, nurses, athletic trainers, or other healthcare providers employed directly or through a contract by the school, or the opposing team’s school. The healthcare providers have my permission to release my child’s medical information to other healthcare practitioners and school officials. In the event I cannot be reached in an emergency I give permission for my child to be transported to receive necessary treatment. I understand that Delaware Interscholastic Athletic Association or its associates may request information regarding the athlete’s health status, and I hereby give my permission for the release of this information as long as the information does not personally identify my child. Parent/Guardian Signature:_______________________________________ Date:_______________
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Athlete’s Signature:_____________________________________________ |
Date:_______________ |
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Section 4: Clearance for Participation |
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__ Cleared without restrictions |
__ Cleared with the following restrictions: |
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Health Care Provider’s Signature:_____________________________________ MD/DO, PA,NP Date:__________ |
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For office use only: This card is valid from April 1, 20_______ through |
June 30, 20________ |
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Note: If any changes occur, a new card should be completed by the parent/guardian. The original card should be |
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kept on file in the school athletic director’s or athletic trainer’s office. A copy should be kept in the sports’ athletic |
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kits. This card contains personal medical information and should be treated as confidential by the school, its |
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employees, agents, and contractors. |
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Name of School: ______________________________ |
Name of ATC: _____________________________ |
PROTECT YOUR ATHLETIC ELIGIBILITY
YOU ARE NOT ELIGIBLE:
1.If you attend a high school and become 19 years of age before June 15 immediately preceding that school year. (Reg. 1009.2.1.1)
2.If you attend a junior high/middle school that terminates in the 8th grade and become 15 years of age before June 15 immediately preceding that school year. (Reg. 1008.2.1.1.1)
*3. If you are not legally enrolled at the school which you represent. (Reg. 1008.2.3.1 and Reg. 1009.2.3.1)
4.If you are not residing with your custodial parent(s), court appointed legal guardian(s), Relative Caregiver, or are a student 18 years of age or older and living in the attendance zone of the school you attend unless you are participating in the Delaware School Choice Program, attend a private school or are a boarding school student. IF YOUR CUSTODIAL PARENT(S), LEGAL GUARDIAN(S) OR RELATIVE
CAREGIVER(S) RELOCATES TO A DIFFERENT ATTENDANCE ZONE, YOU MUST NOTIFY YOUR ATHLETIC DIRECTOR IMMEDIATELY. (Reg. 1008.2.2.1 and Reg. 1009.2.2.1)
*5. If you were absent unexcused or absent due to illness or injury; have been suspended (in-school or out-of-school); or have been assigned to
homebound instruction or an alternative school for disciplinary reasons. (Reg. 1008.2.3.4 and 1008.2.3.5 Reg. 1009.2.3.5 and 1009.2.3.6)
6. If you failed to complete the preceding semester for reasons other than personal illness or injury. (Reg. 1008.2.3.6; Reg. 1009.2.3.7)
*7. If you do not pursue a regular course of study and pass at least five credits per marking period (equivalent of four credits in junior high/middle school), two credits of which must be in the areas of Mathematics, Science, English, or Social Studies. IF YOU ARE
A SENIOR, YOU MUST PASS ALL COURSES WHICH SATISFY AN UNMET GRADUATION REQUIREMENT. (Reg. 1008.2.6.; Reg. 1009.2.6.1)
8.A student who has previously participated in interscholastic athletics that transfers more than one time during their first year of eligibility shall be ineligible in any sport for a period of ninety (90) school days commencing with the first day of official attendance in the receiving school. The period of ineligibility shall continue to the next grade/school year until 90 school days have passed.
9.If you transfer after the first day of school of your second year of high school, you are ineligible to participate in any sport you previously participated in for a period of one school year ( Reg. 1009.2.4)
10.If you participated in the Delaware School Choice Program during the previous academic year and transferred to your “home school” for the current academic year without completing your two-year commitment or receiving a release from the sending school. (Reg. 1008.2.3.3; Reg. 1009.2.3.4)
11.If you participated in the Delaware School Choice Program during the previous academic year and transferred to another “choice school” for the current academic year unless you are playing a sport not sponsored by the sending school. (Reg. 1008.2.4.6.1; Reg. 1009.2.4.7.1)
12If you reached the age of majority (18), occupied a residence in a different attendance zone than your custodial parent(s) or court appointed legal guardian(s), and have not been in regular attendance at your receiving school for at least 90 school days unless you are participating in the Delaware School Choice Program and your application was properly submitted prior to your change of residence. (Reg. 1009.2.2.1.7)
13.If you attend a high school and more than four years has elapsed since you first entered 9th grade, or more than five years has elapsed since you just entered 8th grade in schools with 8th grade eligibility for high school sports. (Reg. 1009.2.7.1 and 2.7.2.1)
14.If you attend a junior high/middle school in which only grades 7-8 are permitted to participate in interscholastic athletics and more than two years has elapsed since you first entered 7th grade. (Reg. 1008.2.7.1)
15.If you attend a junior high/middle school in which grades 6-8 are permitted to participate in interscholastic athletics and more than three years has elapsed since you first entered 6th grade. (Reg. 1008.2.7.2)
16.If you have played on or against a professional team or have accepted cash or a cash equivalent (savings bond, certificate of deposit, etc.); a merchandise item(s) with an aggregate retail value of more than $150; a merchandise discount; a reduction or waiver of fees; a gift certificate or other valuable consideration for athletic participation. (Reg. 1009.2.5.1.4 and 2.5.1.5)
17.If you have used your athletic status to promote a commercial product or service in an advertisement or personal appearance. (Reg. 1009.2.5.1.7)
18.If you have not received a physical examination from a licensed physician (M.D. or D.O.), a certified nurse practitioner or a certified physician’s assistant on or after April 1 and written consent from your custodial parent(s) or court appointed legal guardian(s) to participate in interscholastic athletics is not on file in the school office. (Reg. 1009.3.1.1.1 and Reg. 1008.3.1.1)
19.If you participate in an all-star game not approved by DIAA before you graduate from high school. (Reg. 1009.5.4)
20.If you are a foreign exchange student not participating in a two-semester program listed by the Council on Standards for International Educational Travel (CSIET). (Reg. 1009.2.8.1.2)
21.If you are an international student not in compliance with all DIAA regulations including Reg. 1009.2.2 residency requirements. (Reg. 1009.2.8.2)
*IF YOU ARE NOT IN COMPLIANCE WITH THESE REQUIREMENTS, YOU MAY NOT TRY-OUT,PRACTICE, SCRIMMAGE OR PLAY IN A GAME.
NOTE: Consult with your coach, athletic director, or principal for information concerning additional eligibility requirements.
