The document provides information about a pre-participation exam for athletes at Clarion Area High School to be held on August 1st, 2014. It details the schedule for the exam based on athletes' last names and the locations and staff that will be performing various parts of the medical exam. The packet includes forms for medical consent, student information, emergency contacts, insurance verification, and a health history questionnaire.
This document provides information for patients undergoing spine surgery at UMass Memorial Spine Center. It discusses preparing for surgery, including attending an education class and presurgical evaluation. It describes what to expect during hospitalization, such as pain management and mobility. The document outlines post-surgery care like wound care, follow-up appointments, and return to daily activities and work. The goal is to help patients understand all aspects of their spine surgery and recovery.
This document provides information to help prepare a patient for total hip replacement surgery at UMass Memorial Medical Center. It discusses the hospital's nationally recognized orthopedic team. It outlines the steps patients should take before surgery, including classes, appointments, home preparations, and what to bring to the hospital. It also describes the surgical process and in-hospital recovery, including physical therapy, pain management, and preventing blood clots. The document provides guidance for at-home exercises and care after discharge.
André Menezes é um surfista deficiente auditivo de sucesso com vários títulos nacionais e internacionais. Seu objetivo é treinar em melhores ondas e competir em alto nível com o apoio de patrocinadores. Ele oferece duas opções de patrocínio anual ou por evento para empresas que queiram se associar à sua imagem.
O documento discute a importância do planejamento no treinamento esportivo, destacando que ele existe desde os Jogos Olímpicos da Antiguidade. Explica que o planejamento é um processo científico que auxilia o atleta a atingir alto nível de desempenho, considerando fatores como o potencial do atleta. Também descreve os diferentes tipos de planos de treinamento, como sessões, microciclos e macrociclos.
This document contains a medical history questionnaire for a fitness program participant to complete. It requests personal information, medical history, family medical history, and other health risk factors. The extensive form will be used to evaluate the participant's health and design an individualized exercise program. The participant is asked to carefully and thoroughly complete the form and review it for accuracy before submitting it.
This document is a middle school athletic participation form containing information about a student's personal details, insurance coverage, health history, physical exam results, eligibility requirements, assumptions of risk, transportation policies, sportsmanship pledges, and parental permissions for the student to participate in various sports. The form requires signatures from the student, parents, and school administration.
This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, impact of hospitalization, appropriate play therapy, and safety considerations. The patient's presenting signs and symptoms, height, weight, heart rate, respiratory rate, blood pressure, and temperature are recorded along with any allergies, pain scale, diet, IV fluids, and weight changes. A full physical exam including integumentary, neurological, respiratory, cardiovascular, musculoskeletal, and gastrointestinal systems is documented.
This document is a staff application form for an organization. It requests a variety of personal information from the applicant, including contact details, family details, education and experience history, health information, and consent for treatment. The form notes that answers will not necessarily disqualify an applicant and that each application will be carefully considered and prayed about before a decision is made. It collects information over several sections to evaluate an applicant's suitability and commitment for a staff position.
This document provides information for patients undergoing spine surgery at UMass Memorial Spine Center. It discusses preparing for surgery, including attending an education class and presurgical evaluation. It describes what to expect during hospitalization, such as pain management and mobility. The document outlines post-surgery care like wound care, follow-up appointments, and return to daily activities and work. The goal is to help patients understand all aspects of their spine surgery and recovery.
This document provides information to help prepare a patient for total hip replacement surgery at UMass Memorial Medical Center. It discusses the hospital's nationally recognized orthopedic team. It outlines the steps patients should take before surgery, including classes, appointments, home preparations, and what to bring to the hospital. It also describes the surgical process and in-hospital recovery, including physical therapy, pain management, and preventing blood clots. The document provides guidance for at-home exercises and care after discharge.
André Menezes é um surfista deficiente auditivo de sucesso com vários títulos nacionais e internacionais. Seu objetivo é treinar em melhores ondas e competir em alto nível com o apoio de patrocinadores. Ele oferece duas opções de patrocínio anual ou por evento para empresas que queiram se associar à sua imagem.
O documento discute a importância do planejamento no treinamento esportivo, destacando que ele existe desde os Jogos Olímpicos da Antiguidade. Explica que o planejamento é um processo científico que auxilia o atleta a atingir alto nível de desempenho, considerando fatores como o potencial do atleta. Também descreve os diferentes tipos de planos de treinamento, como sessões, microciclos e macrociclos.
This document contains a medical history questionnaire for a fitness program participant to complete. It requests personal information, medical history, family medical history, and other health risk factors. The extensive form will be used to evaluate the participant's health and design an individualized exercise program. The participant is asked to carefully and thoroughly complete the form and review it for accuracy before submitting it.
This document is a middle school athletic participation form containing information about a student's personal details, insurance coverage, health history, physical exam results, eligibility requirements, assumptions of risk, transportation policies, sportsmanship pledges, and parental permissions for the student to participate in various sports. The form requires signatures from the student, parents, and school administration.
This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, impact of hospitalization, appropriate play therapy, and safety considerations. The patient's presenting signs and symptoms, height, weight, heart rate, respiratory rate, blood pressure, and temperature are recorded along with any allergies, pain scale, diet, IV fluids, and weight changes. A full physical exam including integumentary, neurological, respiratory, cardiovascular, musculoskeletal, and gastrointestinal systems is documented.
This document is a staff application form for an organization. It requests a variety of personal information from the applicant, including contact details, family details, education and experience history, health information, and consent for treatment. The form notes that answers will not necessarily disqualify an applicant and that each application will be carefully considered and prayed about before a decision is made. It collects information over several sections to evaluate an applicant's suitability and commitment for a staff position.
This document contains a student registration form that collects information such as:
- The student's legal name, birthdate, gender, preferred name, address, grade, last school attended.
- Contact information for parents/guardians, emergency contacts, and medical information such as health conditions, medications, doctors.
- Demographic information like ethnicity, language spoken at home, homeless status.
- Permission forms for things like releasing student information, sharing immunization records, taking field trips, and conducting vision screenings.
The form collects important personal details about the student and family to register the student at the school and address any medical or academic needs.
The medical statement document provides information for participants in a scuba diving training program. It details some potential health risks of scuba diving and conduct requirements. Participants must complete a medical questionnaire to assess fitness for diving. Certain medical conditions like asthma, heart disease and seizures pose severe risks for scuba diving and require physician consultation. Proper use of scuba equipment and following safety procedures are essential to reduce risks, but diving may still be dangerous if a person is extremely overweight, out of shape or has respiratory, heart or lung conditions.
This document is a registration form and waiver for a girls' basketball camp run by Evangelical Christian School (ECS). Parents are asked to fill out contact and medical information for their child and sign a waiver releasing ECS of liability. The waiver allows the school to seek medical treatment if the child is injured during camp activities. The form provides details on the camp including dates, location, cost, and highlights of the camp which include drills, skill work, scrimmages, and taking home a workout plan. Biographies of the coaches, Jeff Little and Tavis Rutherford, are included emphasizing their basketball experience.
The document is a health statement and medical release form for campus recreation activities at the University of Nebraska. It requires participants to disclose any medical conditions or medications that could impact their participation or safety. It also obtains consent to emergency medical treatment if needed and acknowledges the participant/guardian's financial responsibility for any costs incurred. The participant/guardian agrees to abide by any activity restrictions set by campus recreation.
This document contains a 34-question health history and lifestyle worksheet for a new client. It collects information about the client's contact details, schedule, medical history, current physical activity level and goals, perceived barriers to exercise, stress levels, and access to fitness equipment to help design a safe and effective personalized exercise program.
This document is a medical release form for Eagle Bluff Environmental Learning Center. It requests information such as the student's name, date of birth, emergency contacts, insurance information, medical conditions, medications, and activity level. The parent or guardian must sign to authorize their child's participation and to release Eagle Bluff from liability. It also allows Eagle Bluff staff to seek medical treatment if needed and for the parent to be responsible for any associated costs.
This document contains a health, fitness, and nutrition status questionnaire completed by a client. It consists of 7 parts that assess personal information, medical history, health behaviors, psychological factors, goals, exercise habits, nutrition knowledge and habits, and dietary supplement use. The questionnaire collects information through multiple choice and rating scale questions to provide an overview of the client's current health, fitness level, diet and needs to inform personalized training and nutrition recommendations.
This health history form collects information from an individual in order to identify any health risks associated with physical activity and exercise. It asks questions about medical conditions like diabetes, pregnancy, surgery, heart issues, injuries, medications, and fitness goals. The individual certifies that the information is true and acknowledges the risks of beginning a new fitness program without medical approval.
The document is a registration form for the Washington State University Tri-Cities Cougar Discovery High School Summer Academic Camp held from June 27-30, 2016 in Richland, WA. It requests student and parent/guardian contact information as well as emergency medical information. The form also includes releases for emergency medical treatment, use of images, and assumption of risk. Students select their first and second choice majors that they will explore during the camp.
This physical examination clearance form requires a medical evaluation and clearance for students to participate in athletic activities. It includes sections for student information, examiner certification of physical fitness or restrictions, classification of sports by contact and intensity, and examiner signature and date. The examiner must certify that the student is physically fit to participate, specify any restrictions, and confirm that a physical exam is on file in their office.
This physical examination clearance form must be completed before a student can participate in athletic activities. It requires medical clearance and certification that the student is physically fit to participate, with any restrictions noted. Sports are classified based on contact and intensity levels. The examiner has examined the student and found no clinical reasons to restrict participation in the sports checked on the form. Emergency contact information and any relevant medical details are also collected. The student and parent consent to the student's participation, disclosure of information to the athletic association, medical treatment if needed, and compliance with athletic policies.
This document contains a new patient medical information form for the podiatry group Drs. Susan & Brad Mattison. The form collects personal information like name, date of birth, ethnicity, contact details, weight, blood pressure, and family medical history. It also asks about social habits like smoking and drinking. Finally, the form inquires about the patient's medical history including conditions like diabetes, heart disease, arthritis, and allergies. It requests details of past surgeries and the reason for the visit.
Medical Certificate Form 1.pdf(Athletes)LizaBacudo2
This document is a medical certificate for school sports participation from the elementary level up to the Palarong Pambansa (National Games) in the Philippines. It contains a physical examination checklist to determine fitness to participate, which includes evaluation of eyes, ears, cardiovascular system, lungs and other areas. The physician examines the student and indicates whether systems are normal or abnormal. Height, weight, blood pressure and other vital signs are also recorded at each level of competition. The physician signs with their name, license and date to certify whether the student is physically fit or unfit to participate.
The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, hospitals and supervising clinicians. Signatures and credentials of supervisors and the dean are provided to validate the documented experiences.
The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, anesthesia used, treating physicians and hospital. Signatures of the clinical supervisor, chief nurse and dean are included to verify the documented experiences.
(1) This document provides registration information for a summer kids' camp taking place from August 22-28, 2010. It includes forms for camper medical history, permission, and medication dosing.
(2) Campers must submit a $100 non-refundable deposit by July 1 for early registration, or pay the full $225 fee for late registration after July 1. Final payments are due by July 22.
(3) The forms request medical information, permission to administer typical over-the-counter medications, and details on any prescription medications the camper will bring to ensure proper dosing.
This new patient form collects information such as contact details, insurance, medical history, and current symptoms from a new patient of Pappas Chiropractic Center. Preliminary screening tests will be done to determine if chiropractic care is suitable, and if not, the patient will be referred to another physician. The form requests details on insurance, primary care physician, current and past medical conditions, current pain levels and locations, and authorizes the chiropractic center to file insurance claims and receive medical records from other providers.
This new patient form collects information such as contact details, insurance, medical history, and current symptoms from a new patient of Pappas Chiropractic Center. Preliminary screening tests will be done to determine if chiropractic care is suitable, and if not, the patient will be referred to another physician. The form asks about the patient's medical providers, conditions, medications, and symptoms. It also contains statements regarding financial responsibility and release of medical information.
1) This document is a registration and medical consent form for a youth basketball league sponsored by the School of Skills.
2) It requests basic contact and medical information for registration purposes and provides consent for emergency medical treatment if needed.
3) Parents must sign to acknowledge participation is voluntary, release the School of Skills from liability, and consent to potential photography for promotional purposes.
This document contains a student registration form that collects information such as:
- The student's legal name, birthdate, gender, preferred name, address, grade, last school attended.
- Contact information for parents/guardians, emergency contacts, and medical information such as health conditions, medications, doctors.
- Demographic information like ethnicity, language spoken at home, homeless status.
- Permission forms for things like releasing student information, sharing immunization records, taking field trips, and conducting vision screenings.
The form collects important personal details about the student and family to register the student at the school and address any medical or academic needs.
The medical statement document provides information for participants in a scuba diving training program. It details some potential health risks of scuba diving and conduct requirements. Participants must complete a medical questionnaire to assess fitness for diving. Certain medical conditions like asthma, heart disease and seizures pose severe risks for scuba diving and require physician consultation. Proper use of scuba equipment and following safety procedures are essential to reduce risks, but diving may still be dangerous if a person is extremely overweight, out of shape or has respiratory, heart or lung conditions.
This document is a registration form and waiver for a girls' basketball camp run by Evangelical Christian School (ECS). Parents are asked to fill out contact and medical information for their child and sign a waiver releasing ECS of liability. The waiver allows the school to seek medical treatment if the child is injured during camp activities. The form provides details on the camp including dates, location, cost, and highlights of the camp which include drills, skill work, scrimmages, and taking home a workout plan. Biographies of the coaches, Jeff Little and Tavis Rutherford, are included emphasizing their basketball experience.
The document is a health statement and medical release form for campus recreation activities at the University of Nebraska. It requires participants to disclose any medical conditions or medications that could impact their participation or safety. It also obtains consent to emergency medical treatment if needed and acknowledges the participant/guardian's financial responsibility for any costs incurred. The participant/guardian agrees to abide by any activity restrictions set by campus recreation.
This document contains a 34-question health history and lifestyle worksheet for a new client. It collects information about the client's contact details, schedule, medical history, current physical activity level and goals, perceived barriers to exercise, stress levels, and access to fitness equipment to help design a safe and effective personalized exercise program.
This document is a medical release form for Eagle Bluff Environmental Learning Center. It requests information such as the student's name, date of birth, emergency contacts, insurance information, medical conditions, medications, and activity level. The parent or guardian must sign to authorize their child's participation and to release Eagle Bluff from liability. It also allows Eagle Bluff staff to seek medical treatment if needed and for the parent to be responsible for any associated costs.
This document contains a health, fitness, and nutrition status questionnaire completed by a client. It consists of 7 parts that assess personal information, medical history, health behaviors, psychological factors, goals, exercise habits, nutrition knowledge and habits, and dietary supplement use. The questionnaire collects information through multiple choice and rating scale questions to provide an overview of the client's current health, fitness level, diet and needs to inform personalized training and nutrition recommendations.
This health history form collects information from an individual in order to identify any health risks associated with physical activity and exercise. It asks questions about medical conditions like diabetes, pregnancy, surgery, heart issues, injuries, medications, and fitness goals. The individual certifies that the information is true and acknowledges the risks of beginning a new fitness program without medical approval.
The document is a registration form for the Washington State University Tri-Cities Cougar Discovery High School Summer Academic Camp held from June 27-30, 2016 in Richland, WA. It requests student and parent/guardian contact information as well as emergency medical information. The form also includes releases for emergency medical treatment, use of images, and assumption of risk. Students select their first and second choice majors that they will explore during the camp.
This physical examination clearance form requires a medical evaluation and clearance for students to participate in athletic activities. It includes sections for student information, examiner certification of physical fitness or restrictions, classification of sports by contact and intensity, and examiner signature and date. The examiner must certify that the student is physically fit to participate, specify any restrictions, and confirm that a physical exam is on file in their office.
This physical examination clearance form must be completed before a student can participate in athletic activities. It requires medical clearance and certification that the student is physically fit to participate, with any restrictions noted. Sports are classified based on contact and intensity levels. The examiner has examined the student and found no clinical reasons to restrict participation in the sports checked on the form. Emergency contact information and any relevant medical details are also collected. The student and parent consent to the student's participation, disclosure of information to the athletic association, medical treatment if needed, and compliance with athletic policies.
This document contains a new patient medical information form for the podiatry group Drs. Susan & Brad Mattison. The form collects personal information like name, date of birth, ethnicity, contact details, weight, blood pressure, and family medical history. It also asks about social habits like smoking and drinking. Finally, the form inquires about the patient's medical history including conditions like diabetes, heart disease, arthritis, and allergies. It requests details of past surgeries and the reason for the visit.
Medical Certificate Form 1.pdf(Athletes)LizaBacudo2
This document is a medical certificate for school sports participation from the elementary level up to the Palarong Pambansa (National Games) in the Philippines. It contains a physical examination checklist to determine fitness to participate, which includes evaluation of eyes, ears, cardiovascular system, lungs and other areas. The physician examines the student and indicates whether systems are normal or abnormal. Height, weight, blood pressure and other vital signs are also recorded at each level of competition. The physician signs with their name, license and date to certify whether the student is physically fit or unfit to participate.
The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, hospitals and supervising clinicians. Signatures and credentials of supervisors and the dean are provided to validate the documented experiences.
The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, anesthesia used, treating physicians and hospital. Signatures of the clinical supervisor, chief nurse and dean are included to verify the documented experiences.
(1) This document provides registration information for a summer kids' camp taking place from August 22-28, 2010. It includes forms for camper medical history, permission, and medication dosing.
(2) Campers must submit a $100 non-refundable deposit by July 1 for early registration, or pay the full $225 fee for late registration after July 1. Final payments are due by July 22.
(3) The forms request medical information, permission to administer typical over-the-counter medications, and details on any prescription medications the camper will bring to ensure proper dosing.
This new patient form collects information such as contact details, insurance, medical history, and current symptoms from a new patient of Pappas Chiropractic Center. Preliminary screening tests will be done to determine if chiropractic care is suitable, and if not, the patient will be referred to another physician. The form requests details on insurance, primary care physician, current and past medical conditions, current pain levels and locations, and authorizes the chiropractic center to file insurance claims and receive medical records from other providers.
This new patient form collects information such as contact details, insurance, medical history, and current symptoms from a new patient of Pappas Chiropractic Center. Preliminary screening tests will be done to determine if chiropractic care is suitable, and if not, the patient will be referred to another physician. The form asks about the patient's medical providers, conditions, medications, and symptoms. It also contains statements regarding financial responsibility and release of medical information.
1) This document is a registration and medical consent form for a youth basketball league sponsored by the School of Skills.
2) It requests basic contact and medical information for registration purposes and provides consent for emergency medical treatment if needed.
3) Parents must sign to acknowledge participation is voluntary, release the School of Skills from liability, and consent to potential photography for promotional purposes.
1. Clarion Area High School Pre-Participation Exam
Dear Parents,
At Clarion High School, the athletic training staff require that all athletes that intend to participate in athletics
take part in a Pre-Participation Exam. All paper work must be completed by athlete or parent prior to
examination. Examinations will be held at Clarion Area High School on Saturday, August 1st, 2014. Price of
examination will be $10.00. All athletes with last names beginning with letters A through G are to arrive at the
school at 8am, H through N are to arrive at 10:30am, O through U are to arrive at 1:00pm, and V through Z are
to arrive at 3:30pm. Please bring the following packet with all forms that are able to be completed prior,
completed. Due to the large number of athletes that need to be tested, please be patient and courteous of all
other athletes and medical professionals as we are trying to facilitate a quick, and easy examination. The
examinations are to be done station based, utilizing the Certified Athletic Training Devin Skinner, Team Family
Physician Dr. Jan Kenneson, Athletic Director Robert Walters, and Team Orthopedic Surgeon Dr. Robert
Armstrong to perform each aspect of the exams. Athletes will meet in the lobby area to check in and give all
medical history information (all forms in packet besides physical examination information form) to Mr. Walters
and will be assigned a station where they will begin. The physical exam will be done by Dr. Kenneson in the
nurses’ office, orthopedic screening will be done by orthopedic surgeon Dr. Armstrong in the ATR, functional
testing, height, weight, and vision done by Mr. Skinner in the gym, and check out. All forms are to be given to
ATC before departure. Below are the locations of each station that the athlete and parent will go through…
1 = check in
2 = physical
examination/medical
history drop-off
3 = orthopedic screening
4 = height/weight
5 = visionscreening
6 = functional testing
7 = check out
2. Medical Consent/Release for Treatment Form
Athlete Name: __________________________ Sport____________________________
I, _____________________________the Parent or Legal Guardian of __________________________, grant
the team physician, certified athletic training and associated medical staff to medically treat my child who is a
minor. I allow necessary examination and medical treatment by certified athletic trainer, and accompanied
medical staff of Clarion Area High School. Medical treatment includes but is not limited to: initial evaluations,
assessment evaluations, taping and bracing, stretching, cryotherapy, thermotherapy, rehabilitation exercises, and
administering medications. I am also aware that I am giving consent for my son or daughter to be hospitalized if
necessary at an accredited hospital.
You do have the right to refuse to sign this section of this form. If you do not wish to sign the medical consent
section of this form, please print in the signatures line, REFUSE TO CONSENT, and date the refusal.
Parent/Guardian Signature_____________________________________ Date______________
To be completed by parent and/or guardian
3. Student-Athlete Information
Please complete these information sections.
General Information:
First Name: ____________________________.
Middle Initial: ______________.
Last Name: _____________________________.
Sex: Male / Female (circle one)
Date of Birth (mm/dd/yy): ___ /___ /___
Student's SSN: ___________________.
Height (ft., in.):__________________.
Weight (lbs): ___________________.
Student Cell Phone: ( ) – ( ) – ( )
Primary Address:
Address: __________________________________________________________.
City: _______________________________________.
State/Province: ______________.
Zip Code: __________________.
To be completed by parent and/or guardian
4. Health Emergency Contact Information
Please complete these information sections.
First EmergencyContact Name:____________________________________
Relationship toStudentAthlete: ____________________________________
Address: ________________________________________________.
City: ___________________________________.
State/Province: _______________.
Zip Code: _____________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
Second EmergencyContactName: ___________________________________
Relationship toStudent-Athlete: ______________________________________
Address: _________________________________________________.
City: ___________________________________.
State/Province: _____________.
Zip Code: ______________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
Third EmergencyContact Name:___________________________________
Relationship toStudent-Athlete: ______________________________________
Address: _________________________________________________.
City: ___________________________________.
State/Province: _____________.
Zip Code: ______________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
To be completed by parent and/or guardian
5. Clarion Area High School Insurance Verification Form
Please Scan Insurance Card and complete the information by 08/1/14.
Name: ___________________________
Date: ____________________________
Medical (Primary):
Company Name: __________________________________________.
Plan ID: _________________________________.
Group Number: __________________________.
Primary Subscriber: ________________________________.
Subscriber's Date of Birth: ( ) / ( ) / ( ).
Subscriber/policy ID: _________________.
Insurance phone: __________________________.
Status:________________________.
To be completed by parent and/or guardian
Front of Card
Back of Card
6. Health History Questionnaire
Please have athlete answer yes or no to all questions honestly.
General Health Questions:
1. Do you have any allergies? (if yes, please explain)______________________________________________________.
2. Do you take any medications? (if yes, please explain)___________________________________________________.
3. Do you have any on-going medical conditions? Ex. Diabetes, asthma, infections (if so, please explain)
_______________________________________________________________________________________.
4. Has a doctor ever denied or restricted your participation in sports for any reason? (if so, please
explain)_______________________________________________________________________________________.
5. Have you ever had surgery of any kind? (if so, list all procedures and
dates)_________________________________________________________________________________________.
6. Have you ever spent a night in the hospital? (if so, for what and give dates of
visit)_________________________________________________________________________________________
Heart Health Questions about you and your family:
7. Does anyone in your family have the diseases hypertrophic cardiomyopathy, Marfan syndrome, arrhythmgenic right
ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia? (if so, please explain)_____________________________________________
_____________________________________________________________________________________________.
8. Have you ever passed out or nearly passed out DURINGor AFTER exercise? (if so, please
explain)_______________________________________________________________________________________.
9. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? (if so, please
explain)_______________________________________________________________________________________.
10. Have you ever been told you that you have high blood pressure? (if so, please
explain)_______________________________________________________________________________________.
11. Have you ever told that you have a heart murmur? (if so, please explain)____________________________________.
12. Have you ever had a doctor order a heart test for you? Ex. EKG, ECG, echocardiogram (if so, please explain)
_______________________________________________________________________________________.
13. Have you ever had an unexplained seizure? (if so, please explain and give date of last
seizure)________________________________________________________________________________________.
14. Has any family member ever died as a result of a heart condition or had an unexplained sudden death before the age
of 50? (if so, please explain)_______________________________________________________________________.
15. Does anyone in your family have a heart problem, pacemaker,or implanted defibrillator? (if so, please
explain)_______________________________________________________________________________________.
Bone and Joint Questions:
16. Have you ever had a bone or joint injury that caused you to miss a practice or a game? Ex. Ligaments, muscles,
tendons, or bones (if so, please explain) ______________________________________________________________.
7. 17. Have you ever had any broken or fractured bones or dislocated joints? (if so, please
explain)_______________________________________________________________________________________.
18. Have you ever had an injury that required x-rays, MRI, CT scan,injections, therapy, a brace,a cast,or crutches? (if
so, please explain)______________________________________________________________________________.
19. Do you regularly use a brace,orthotics, or other assistive devices? (if so, please
explain)______________________________________________________________________________________.
20. Have you ever been diagnosed with a stress fracture? (if so, please explain and give a
location)______________________________________________________________________________________.
21. Do you have a bone, muscle, or joint injury that bothers you? (if so, please
explain)_______________________________________________________________________________________.
22. Have you ever had an x-ray for neck instability or atlantoaxial instability? (if so, please
explain)_______________________________________________________________________________________.
23. Do you have any history of juvenile arthritis or any connective tissue diseases? (if so, please
explain)_______________________________________________________________________________________.
Medical Questions:
24. Do you have asthma or use a prescribed medical inhaler, or has anyone in your family ever had asthma? (if so, please
explain)_______________________________________________________________________________________.
25. Are you updated on all your immunizations? (if so, please explain)________________________________________.
26. Diabetes? (if so, please explain)____________________________________________________________________.
27. Were you born with a vital organ missing? Ex. Testicle, kidney, eye, spleen (if so, please explain)
_______________________________________________________________________________________.
28. Have you ever been unable to move your arms or legs after a hit or fall? (if so, please
explain)_______________________________________________________________________________________.
29. Have you ever had any numbness or tingling in your arms or legs after a hit or fall? (if so, please
explain)_______________________________________________________________________________________.
30. Have you ever had a groin pain or a hernia? (if so, please explain)_________________________________________.
31. Have you ever had Herpes or MIRSA skin infections? (if so, please
explain)_______________________________________________________________________________________.
32. Have you ever become ill from exercising in the heat? (if so, please
explain)_______________________________________________________________________________________.
33. Do you get frequent muscle cramps when exercising? (if so, please explain)_________________________________.
34. Epilepsy? (if so, please explain)____________________________________________________________________.
35. Seizures/Convulsions? (if so, please explain)__________________________________________________________.
36. Heart Condition? (if so, please explain)______________________________________________________________.
37. Kidney Problems? (if so, please explain)_____________________________________________________________.
38. Migraine: Frequent Headache? (if so, please explain)___________________________________________________.
39. Concussion/Head Injury? (if so, please explain)_______________________________________________________.
40. Psychological Treatment? (if so, please explain)______________________________________________________.
8. 41. Hyperactivity/Attention Deficit? (if so, please explain)_________________________________________________.
42. Have you ever been worried about your weigh or had a history of any eating disorders? Ex. Anorexia Nervosa or
Bulimia? (if so, please explain)___________________________________________________________________.
43. Do you have a family member who has been diagnosed with cancer? (if so, please
explain)______________________________________________________________________________________.
44. Pneumonia? (if so, please explain)_________________________________________________________________.
45. Thyroid Problems? (if so, please explain)____________________________________________________________.
46. Chicken Pox (if so, please explain) _________________________________________________________________.
47. Fainting? (if so, please explain)_____________________________________________________________________.
48. Recent or Chronic Infections? (if so, please explain)____________________________________________________.
49. Frequent Sore Throats? (if so, please explain)_________________________________________________________.
50. Frequent Ear Infection? (if so, please explain and list how many)__________________________________________.
51. Frequent Bronchitis? (if so, please explain)___________________________________________________________.
52. Frequent Nose Bleeds? (if so, please explain and list how many)__________________________________________.
53. Motion Sickness? (if so, please explain)______________________________________________________________.
54. Scoliosis? (if so, please explain)____________________________________________________________________.
55. Hearing Impairment? (if so, please explain)___________________________________________________________.
56. Wears any sort of corrective lenses. Ex. Glasses or contacts (if so, please explain) ____________________________.
57. Premature Birth or Problems at Birth? (if so, please explain)______________________________________________.
58. Any Major Surgeries? (if so, please explain)__________________________________________________________.
59. Any Major Injuries? (if so, please explain)____________________________________________________________.
60. Tuberculosis? (if so, please explain)________________________________________________________________.
61. Rheumatic Fever? (if so, please explain)______________________________________________________________.
62. Sickle Cell Anemia? (if so, please explain)____________________________________________________________.
63. Any other pertinent conditions not listed above? (if so, please explain)______________________________________.
Females only:
64. Have you ever had a menstrual period? (if so, please list the date of your last cycle)___________________________.
65. How old were you when you had your first period? ____________________________________________________.
66. How many periods have you had in the last 12 months? _________________________________________________.
I hereby state that, to the best ofmy knowledge, my answers to the above questions are complete and correct.
Signature of Athlete_________________________________________ Date: __________________
Signature of Parent and/or Guardian___________________________________________ Date:__________________
To be signed and completed by athlete
9. Clarion Area High School Physical Examination Form
(To be filled out by physician)
Student’s Name_____________________________ Type of Sport___________________ Date: ___/___/___
Height_________ Weigh: ____________ Pulse___________ Blood Pressure_________ / __________
Visual Acuity: Right 20/_____ Left 20/_____ Corrected: Yes / No Pupils Equal: ______ Unequal ______
FINDINGS NORMAL PHYSICIAN NOTES
MEDICAL
1. Appearance ____________________ __________________________________
2. Eyes/Ears/Nose/Throat ____________________ __________________________________
3. Lymph Nodes ____________________ __________________________________
4. Heart ____________________ __________________________________
5. Pulses _____________________ __________________________________
6. Lungs _____________________ __________________________________
7. Abdomen _____________________ __________________________________
8. Genitalia (males only) _____________________ __________________________________
9. Skin _____________________ __________________________________
10. Urinalysis _____________________ __________________________________
11. History of Concussions _____________________ __________________________________
MUSCULOSKELETAL
1. Neck _______________________ __________________________________
2. Back _______________________ __________________________________
3. Shoulder/Arm ________________________ __________________________________
4. Elbow/Forearm ________________________ __________________________________
5. Wrist/Hand ________________________ ___________________________________
6. Hip/Knee ________________________ ___________________________________
7. Knee ________________________ ___________________________________
8. Leg ________________________ ___________________________________
9. Foot ________________________ ___________________________________
ASSESSMENT
_____ Cleared without limitation
Cleared after completing evaluation/ rehabilitation for_____________________________________________.
______ NOT CLEARED for: _____________________________ Reason: _____________________________
_________________________________________________________________________________________.
11. Justification Paper
Each year, between seventeen and twenty-five million adolescents engage in some type of sports related
activity, and each year more than two million injuries occur requiring doctor’s visits and hospitalizations. Since
August of 2010, at least fourteen high school and youth football players have died during or a result of athletic
participation. One of the most important aspects of preventing injury or sudden death in athletes is detecting
any underlying health problems before the athlete begins participation. Some of the main questions that the
medical history form asks the athlete is information regarding both themselves, and their family members. The
reason for this, is that sometimes diseases or health problems are passed down through generations, and the
athlete could be unaware of them. A thorough medical history can reveal up to seventy-five percent of
conditions that would limit or alter sports participation, and in conjunction with a musculoskeletal testing most
athletes do prove to be very healthy. The questions that are asked are all inclusive and hit the major categories
such as psychological issues, eating disorders, medications, past concussions, previous surgeries, allergies,
heart-health problems, and even past musculoskeletal injuries. The medical aspect of the physical form that is to
be completed by a physician is to make sure that the athlete has healthy vitals, the athletes vision is correct, and
the major systems of the body are all functioning properly (i.e. respiratory, circulatory, etc.). The
musculoskeletal aspect of the physical form is to detect any mechanical abnormalities in the joints from past
injuries, or any weakness that may predispose the athlete to injury for the upcoming season. Only about three to
thirteen percent of all athletes who participate in a pre-participation exams require further evaluation, but it can
make all the difference if a medical emergency were to occur.
The other forms include the medical release form which states that the parent and/or guardian is granting
the physician, certified athletic trainer, and all associated medical staff ability to treat the athletes to the best of
their abilities. This is crucial for all the medical staff to make sure that law suits do not arise from any claims of
malpractice. The student-athlete information card that gives the athletic trainer the ability to access any
pertinent information if the athlete were to ever have to go to the emergency room or hospital. Also, the
athlete’s address is provided in case there were to be any billing information, or doctor’s notes that needed to be
sent to the athlete’s parent and/or guardian. The next form is the emergency contact information which is
utilized in situations where there may be a medical emergency and the athlete’s parent and/or guardian needs to
be informed; Three contacts are to be given in case the first two are not reachable at the time of emergency.
The insurance verification form is just that, a way for the athletic trainer to send any information to physicians
or hospitals for billing services, and to ensure that the athlete is covered in case an injury is to occur. All
information on the insurance card should be filled out in the lines provided, in addition to a photo-copy of the
insurance card itself. All of these forms are very crucial to the pre-participation exam, and are created to help
the certified athletic trainer provide the best care for the athlete and prevent injury from occurring.