Lhsaa Medical History Evaluation Form PDF Details

The LHSAA Medical History Evaluation form is a crucial document designed to safeguard the health and safety of student athletes by gathering comprehensive health information annually. This requirement not only facilitates a better understanding of the student's medical and orthopedic history but also establishes a baseline for monitoring potential health risks associated with sports participation. The form covers a wide range of details, from personal and family medical history to specifics about prior injuries and conditions that may impact the student's ability to engage safely in sports activities. Additionally, it outlines the conditions under which emergency medical treatment can be authorized, ensuring that swift and appropriate measures can be taken in the event of an injury or sickness. The waiver section further details the legal understanding between the student athlete, their guardian, and the volunteer healthcare provider, highlighting the limited nature of the physical screening and the specific legal protections in place for volunteers under Louisiana law. By requiring a detailed account of the athlete's medical background and current health status, completed and updated annually, this form plays a vital role in preventive health measures and in promoting a safe sporting environment.

QuestionAnswer
Form NameLhsaa Medical History Evaluation Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslhsaa medical history evaluation, lhsaa medical history evaluation 2021, lhsaa medical, lhsaa medical history evaluation form

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LHSAA MEDICAL HISTORY EVALUATION

IMPORTANT: This form must be completed annually, kept on file with the school, & is subject to inspection by the Rules Compliance Team.

PLEASE PRINT

Name:___________________________________________________School:______________________________________________Grade:________Date:______________

Sport(s):_________________________________________________________Sex: M / F Date of Birth:_____________Age:______Cell Phone:_____________________

Home Address:___________________________________City:__________________________State:_____ Zip Code:___________Home Phone:____________________

Parent / Guardian:________________________________________________Employer:_______________________________________Work Phone:__________________

FAMILY MEDICAL HISTORY: Has any member of your family under age 50 had these conditions?

 

 

Yes No Condition

Whom

Yes No Condition

Whom

Yes No Condition

Whom

Heart Attack/Disease

 

Sudden Death

_____________

Arthritis

_____________

Stroke

 

High Blood Pressure

_____________

Kidney Disease

_____________

Diabetes

 

Sickle Cell Trait/Anemia

_____________

Epilepsy

_____________

ATHLETE’S ORTHOPAEDIC HISTORY: Has the athlete had any of the following injuries?

 

 

 

 

 

 

 

Yes No Condition

Date

Yes No Condition

Date

Yes No Condition

Date

Head Injury / Concussion

__________

 

Neck Injury / Stinger

_________

Shoulder L / R

__________

Elbow L / R

__________

 

Arm / Wrist / Hand L / R

_________

Back

__________

Hip L / R

__________

 

Thigh L / R

_________

Knee L / R

__________

Lower Leg L / R

__________

 

Chronic Shin Splints

_________

Ankle L / R

__________

Foot L / R

__________

 

Severe Muscle Strain

_________

Pinched Nerve

__________

Chest

__________

 

Previous Surgeries:

 

 

 

 

 

 

 

 

ATHLETE MEDICAL HISTORY: Has the athlete had any of these conditions?

 

 

 

 

 

 

 

Yes No Condition

 

Yes No Condition

Yes No Condition

 

 

 

Heart Murmur / Chest Pain / Tightness

 

Asthma / Prescribed Inhaler

 

Menstrual irregularities: Last Cycle:

Seizures

 

 

Shortness of breath / Coughing

 

Rapid weight loss / gain

 

 

 

Kidney Disease

 

 

Hernia

 

Take supplements/vitamins

 

 

 

Irregular Heartbeat

 

 

Knocked out / Concussion

 

Heat related problems

 

 

 

Single Testicle

 

 

Heart Disease

 

Recent Mononucleosi

 

 

 

High Blood Pressure

 

 

Diabetes

 

Enlarged Spleen

 

 

 

Dizzy / Fainting

 

 

Liver Disease

 

Sickle Cell Trait/Anemia

 

 

 

Organ Loss (kidney, spleen, etc)

 

Tuberculosis

 

Overnight in hospital

 

 

 

Surgery

 

 

Prescribed EPI PEN

 

Allergies (Food, Drugs)

 

 

 

Medications

 

 

 

 

 

 

 

 

 

 

 

 

 

List Dates for: Last Tetanus Shot:

 

 

Measles Immunization:

 

Meningitis Vaccine:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAIVER FORM

 

 

 

 

 

 

 

To the best of our knowledge, we have given true & accurate information & hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that if the examination is provided without expectation of payment, there shall be no cause of action pursuant to Louisiana R.S. 9:2798 against the team volunteer health- care provider and/or employer under Louisiana law.

1.

If, in the judgment of a school representative, the named student athlete needs care or treatment as a result of an injury

 

 

or sickness, I do hereby request, consent and authorize for such care as may be deemed necessary…………………………………………....Yes

No

2.

I understand that if the medical status 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

3.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

This waiver, executed this ____ day of ________________, 20___, by ____________________, M.D., D.O., APRN or PA and _______________________,

student athlete, is executed in compliance with Louisiana law with the full understanding that there shall be no cause of action for any loss or damage caused by any act or omission related to the health care services if rendered voluntarily and without expectation of payment herein unless such loss or damage was caused by gross negligence.

Typed or Printed Name of Student Athlete

Signature of Parent

Typed or Printed Name of Parent

II. COMPLETED ANNUALLY BY MEDICAL DOCTOR (MD), OSTEOPATHIC DR. (DO), NURSE PRACTITIONER (APRN) or PHYSICIAN’S ASSISTANT (PA)

 

Height ______________

 

Weight __________________

Blood Pressure________________

 

Pulse___________

GENERAL MEDICAL EXAM :

 

 

 

 

OPTIONAL EXAMS:

 

 

ORTHOPAEDIC EXAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Norm

Abnl

 

 

Norm

Abnl

 

 

 

VISION:

 

 

I.

Spine / Neck

 

ENT

 

 

 

 

L:_______ R:_______ Corrected: _______

 

Cervical

 

Lungs

 

 

 

 

 

 

 

 

Thoracic

 

Heart

 

 

 

 

DENTAL:

 

 

 

Lumbar

 

Abdomen

 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

 

II.

Upper Extremity

 

Skin

 

31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

 

Shoulder

 

Hernia (if Needed)

 

 

 

 

 

 

 

 

Elbow

 

 

 

 

 

 

 

 

 

 

 

 

Wrist

 

COMMENTS:

 

 

 

 

 

 

 

 

Hand / Fingers

 

 

 

 

 

 

 

 

 

 

 

 

III.

Lower Extremity

 

 

 

 

 

 

 

 

 

 

 

 

Hip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Knee

 

From this limited screening I see no reason why this student cannot participate in athletics

 

Ankle

 

[ ] Student is cleared

 

 

 

 

 

 

 

 

 

 

 

 

[ ] Cleared after further evaluation and treatment for:

 

 

 

 

 

 

 

 

[ ] Not cleared for: __contact

__non-contact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name of MD, DO, APRN or PA

 

 

 

Signature of MD, DO, APRN or PA

 

 

 

Date

 

* This physical expires one year on the last day of the month that it was signed and dated by the MD, DO, APRN or PA. *

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