Lhsaa Medical History Evaluation Form – Fill Out and Use This PDF

Please Print. Enter Name, School, Grade, Date, Sport(s), Sex, Date of Birth, Age, Cell Phone, Home Address, City, State, Zip Code, Home Phone, Parent / Guardian, Employer and Work Phone.

Has any member of your family under age 50 had these conditions? Mark Yes or No for each condition and write Whom: Heart Attack/Disease, Sudden Death, Arthritis, Stroke, High Blood Pressure, Kidney Disease, Diabetes, Sickle Cell Trait/Anemia, Epilepsy.

Has the athlete had any of these injuries? Mark Yes or No for each condition and enter the 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. Then enter Previous Surgeries.

Has the athlete had any of these conditions? Mark Yes or No for each 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 Mononucleosis, 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.

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.

4. By my signature in Signature of Parent, I am agreeing to allow my child's medical history/exam form and all eligibility forms to be reviewed by the LHSAA or its representative(s) or the associated medical personnel: Yes No. Then fill in Date Signed by Parent, Signature of Parent and Typed or Printed Name of Parent.

Enter Name, Date of Birth, Age, Date, School, Grade and Sport(s).

Enter Height, Weight, Blood Pressure and Pulse.

Section II is completed annually by Medical Doctor (MD), Osteopathic Dr. (DO), Nurse Practitioner (APRN) or Physician's Assistant (PA). General Medical Exam: for ENT, Lungs, Heart, Abdomen and Skin, mark Norm or Abnl. Orthopaedic Exam: for I. Spine / Neck (Cervical, Thoracic, Lumbar), II. Upper Extremity (Shoulder, Elbow, Hand / Fingers, Wrist) and III. Lower Extremity (Knee, Hip, Ankle), mark Norm or Abnl. Health Care Provider notes (if needed). Medically eligible for all sports without restriction; Medically eligible for certain sports; Medically eligible for all sports with recommendations for further evaluation or treatment of; Not medically eligible pending further evaluation; Not medically eligible for any sports. This recommendation is from a limited screening.

Enter Printed Name of MD, DO, APRN or PA, Signature of MD, DO, APRN or PA and Date of Medical Examination.

This physical expires 13 months from the date it was signed and dated by the MD, DO, APRN or PA.