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

Collecting information about a patient's medical history is vital for providing the best care and treatment. The Louisiana High School Athletic Association has developed the Medical History Evaluation Form as an essential part of routine medical assessment. This form includes questions ranging from patterns of previous illnesses or injuries to recurring health conditions, to medications taken and other treatments prescribed by a medical provider. Healthcare professionals can use this form to assess how medical history may influence current recovery and plan further treatments accordingly. Having access to the most up to date information is applicable for residents of all areas. The Medical History Evaluation Form allows Louisiana High School Athletic Association professionals to gain insight into their patient’s condition, which ultimately provides potential pathways towards better healthcare outcomes.

Lhsaa Medical History Evaluation Form PDF Details

As medical history evaluation becomes an increasingly important part of a patient’s care, it's crucial to be well-versed in the forms used for such evaluations. The LHSAA Medical History Evaluation Form is one such form - frequently used in both clinical and research settings - which provides healthcare professionals with an organized way to review a patient's medical records, current medications and treatments, as well as previous health issues. In this blog post, we will delve into what exactly the medical history evaluation form entails and highlight its importance when providing quality healthcare. Whether you're starting your career as a doctor or are looking to keep up with changing standards of care, gaining insight into this vital document cannot be overstated!

Question	Answer
Form Name	Lhsaa Medical History Evaluation Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	lhsaa medical history evaluation, lhsaa medical history evaluation 2021, lhsaa medical, lhsaa medical history evaluation form

Form Preview Example

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

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:

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. *

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

Lhsaa Medical History Evaluation Form PDF Details

Form Preview Example

Lhsaa Medical History Evaluation Form isn’t the one you’re looking for?

Related Documents