Wrestling Skin Form – Fill Out and Use This PDF

Minnesota State High School League

WRESTLING SKIN CONDITION REPORT

PHYSICIAN RELEASE FOR WRESTLER TO PARTICIPATE WITH SKIN LESION

PRIVATE/CONFIDENTIAL DATA

Name:___________________________________________________________ Date of Exam:_____/_____/_____

Mark Location AND Number of Lesion(s)

Diagnosis:__________________________________________

__________________________________________________

Location AND Number of Lesion(s):____________________

_________________________________________________

Medication(s) used to treat lesion(s):____________________

_________________________________________________

Date Treatment Started:_____/_____/_____

Earliest date may return to participation:_____/_____/_____

Form Expiration Date:_____/_____/_____

Physician Signature:_____________________________________________________________________

Physician Name (Printed or Typed):_________________________________________Office Phone #:______________

(M.D. or D.O.)

Office Address:___________________________________________________________________________________

Note: To ensure medical instructions and MSHSL rules are being followed, this form should be faxed to the Activities Director at the student’s school.

Note to providers: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.) Please familiarize yourself with NFHS Rules, 4-2-3 and 4-2-4 which states:

“ART. 3 . . . If a participant is suspected by the referee or coach of having a communicable skin disease or any other condition that makes participation appear inadvisable, the coach shall provide current written documentation as defined by the NFHS or the state associations, from a physician stating that the suspected disease or condition is not communicable and that the athlete’s participation would not be harmful to any opponent. This document shall be furnished at the weigh-in or prior to competition in the dual meet or tournament. Covering a communicable condition shall not be considered acceptable and does not make the wrestler eligible to participate.”

“ART. 4 . . . If an on-site meet physician is present, he/she may overrule the diagnosis of the physician signing the physician’s release form for a wrestler to participate with a particular skin condition.”

Once a lesion is not considered contagious, it may be covered to allow participation.

Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling:

Bacterial diseases (impetigo, boils): To be considered “non-contagious”, all lesions must be scabbed over with no oozing or discharge and no new lesions should have occurred in the preceding 48 hours. Oral antibiotic for three (3) days is considered minimum to achieve that status. If new lesions continue to develop or drain after 72 hours, CA-MRSA (Community Associated Methicillin Resistant Staphylococcus Aureus) should be considered and minimum oral antibiotics should be extended to ten (10) days before returning the athlete to competition or until all lesions are scabbed over, whichever occurs last.

Herpetic lesions (Simplex, Fever blisters/cold sores, Zoster, Gladiatorum): To be considered “non-contagious”, all lesions must be scabbed over with no oozing or discharge and no new lesions should have occurred in the preceding 48 hours. For primary (first episode of Herpes Gladiatorum), wrestlers should be treated and not allowed to compete for a minimum of ten (10) days. If general body signs and symptoms like fever and swollen lymph nodes are present, that minimum period of treatment should be extended to 14 days. With recurrent outbreaks the athlete may return to competition on the 7th day of oral anti-viral treatment, again so long as no new lesions have developed in the last 48 hours and all lesions are scabbed over.

Tinea Lesions (ringworm scalp, skin): Oral or topical treatment for 72 hours on all skin and 14 days on scalp.

Scabies, Head lice: 24 hours after appropriate topical management.

Conjunctivitis: 24 hours of topical or oral medication and no discharge.

Molluscum Contagiosum: 24 hours after curettage.

Parent Signature Required: _____________________________________________

Revised 1/21/2009