ATTACHMENT: Interim Questionnaire & Health Examination & Consent Form

Transcription

1 POLICY TITLE: Athletic Physical Examinations Minidoka County Joint School District # 331 POLICY NO: PAGE 1 of 1 The Board of Trustees of Minidoka County Joint School District No. 331 acknowledges that it is in the best interest of the district's students to establish policies and procedures to protect students and provide a measure of safety for those who wish to participate in athletic contests. All coaching procedures and equipment purchases should be oriented toward decreasing the chance of injury. Therefore, each participating student must have on record with the school the Interim Questionnaire prior to his/her first practice in any as defined by the Idaho High School Activities Association, building principal or the activities director as athletic contests and/or cheerleading. An annual physical examination is required prior to the first day of practice in the 9 th and 11 th grades for each student who participates in the above-defined activities. A student will not be required to have an additional physical examination during the 10 th and 12 th grades unless: 1. The physician recommends the student have an additional physical examination; 2. The parent requests an Examination on the Interim Questionnaire; 3. Affirmative answers on 1-9 of the Interim Questionnaire indicate a possible need for a repeat examination; 4. A transfer participating student had a physical examination during the preceding year in another state. Physical examinations must not be completed before May 1 of the participating students 8 th or 10 th year. The Interim Questionnaire is a consent form that must be completed each year of participation by the parents/guardians of the student. The original must be given the school principal or his/her designee on or before the first day of practice. Any student not receiving proper clearance through a physical examination or Interim Questionnaire may not participate in any practices, meetings, or performances. The physical examination and Interim Questionnaire must be on the approved form which is attached and made part of this policy by inclusion. Should a student be injured during the course of an athletic season, at the discretion of the coach, activities director or principal he/she may be excluded from participation pending a subsequent more thorough analysis by a competent physician prior to reinstatement to the team. LEGAL REFERENCE: Idaho Code and IHSAA Rules ADOPTED: June 1994 AMENDED/REVISED: August 21, 2006 ATTACHMENT: Interim Questionnaire & Health Examination & Consent Form SECTION 300: STUDENT

2 INTERIM QUESTIONNAIRE PLEASE PRINT!! Male/Female Last Name First Middle (circle one) City Date Since his/her last athletic physical examination, has this student: YES NO Year in School (1) Had surgery l (2) Been hospitalized (3) Been under a physician's care (4) Had a serious illness (5) Had an injury requiring a physician's care (6) Been rendered unconscious (7) Started taking any new medications (8) Developed any new drug allergies (9) Developed any health problems (Please explain all yes answers) ========================================================================================== My child should or should not have a physical examination prior to participation in high school athletics. School health insurance needed: Yes No If yes, a premium charge will be required prior to participation in any IHSAA athletic activity. More information may be obtained from the local school district. If no, is your child covered by a family health insurance policy? Yes No Signature of Parent or Guardian Address City Zip Code ========================================================================================== CONSENT FORM I hereby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated by school authorities for any illness or injury resulting from his/her athletic participation. SIGNATURE OF PARENT/GUARDIAN DATE My participation in interscholastic athletics for the above school is entirely voluntary on my part, and with the understanding that I have not violated any of the eligibility rules and regulations of the state association. SIGNATURE OF STUDENT DATE NOTE: The original copy is to be returned to the school.

3 IDAHO HIGH SCHOOL ACTIVITIES ASSOCIATION IDAHO HEALTH EXAMINATION AND CONSENT FORM It is required that all students complete a History and Physical examination prior to his/her first 9th and 11th grade practice in the interscholastic (9-12) athletic program in the State of Idaho. The exam is at the expense of the student and may not be taken prior to May 1 of the 8th and 10th grade years. This examination is to be done by a licensed physician, physician's assistant or nurse practitioner under optimal conditions. Interim history forms are required during the 10th and 12th grade years and must be submitted to the principal prior to the first practice. Name Home Address Phone Grade Sports Personal Physician Physician's phone number Date of Birth Sex School HISTORY FORM *Fill in details of YES answers in space below: YES NO Have you ever been hospitalized? Have you ever had surgery? Are you presently taking any medication or pills? Do you have any allergies (medicine, bees, other stinging insects)? Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you tire more quickly than your friends during exercise? Have you ever had high blood pressure? Have you ever been told you have a heart murmur? Do you have any skin problems? (itching, rash, acne) Have you ever had a head injury? Have you ever been knocked out or unconscious? Have you ever had a seizure? Have you ever had a stinger, burner, or pinched nerve? Have you ever had heat cramps? Have you ever been dizzy or passed out in the heat? Do you have trouble breathing or cough during or after exercise? Do you use special equipment, pads, braces, mouth or eye guards? Have you had problems with your eyes or vision?. Have you ever had racing of your heart or skipped beats? Do you wear glasses, contacts or protective eyewear?. Has anyone in your family died of heart problems or a sudden death before age 50? YES NO. Have you ever sprained/strained, dislocated, fractured/broken, or had repeated swelling or other injuries of any of your bones or joints? Head Neck Chest Back Hip Shoulder Elbow Forearm Wrist Hand Thigh Knee Shin/Calf Ankle Foot Have you ever had any other medical problems such as: Mononucleosis Diabetes Asthma Hepatitis Headaches (frequent) Tuberculosis Eye injuries Stomach ulcer Other Have you had a medical problem or injury since last exam? When was your last tetanus shot? When was your last measles immunization? When was your first menstrual period? When was your last menstrual period? What was the longest time between periods last year? *Explain YES answers here: CONSENT FORM (Parent or Guardian and Student Permission and Approval) I hereby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated by school authorities for any illness or injury resulting from his/her athletic participation. In the absence of parents, I also consent to the release of any information contained in this form to carry out treatment and health care operations for the above named student. PARENT OR GUARDIAN SIGNATURE This application to compete in interscholastic athletics for the above school is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the State Association. SIGNATURE OF STUDENT DATE: DATE:

4 PHYSICAL EXAMINATION FORM Height Weight BP / T Pulse R Visual acuity R 20 / L 20 / Corrected: Y N Pupils Ears, Nose, Throat Normal Abnormal Cardiopulmonary Pulses Heart Lungs Skin Abdominal Genitalia Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot CLEARANCE / RECOMMENDATIONS Clearance: A. Cleared for all sports and other school-sponsored activities. B. Cleared after completing evaluation / rehabilitation for: C. NOT cleared to participate in the following IHSAA sponsored sports: Baseball Cross Country Golf Softball Track Wrestling Basketball Football Soccer Tennis Volleyball Not cleared for other school-sponsored activities: (Example) 1. Swimming D. Student is NOT permitted to participate in high school athletics. Reason: Recommendation: Examiner's Signature: Date: (This Physical form must be signed by a licensed physician, physician's assistant or nurse practitioner) Address: Phone: 4

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