Nauset Regional High School

Athletic Training

Medical History and Consent Form

For Office Use Only

Date to Athletic Office: ______Physical Date: ______

Impact Date: ______Parent Meeting: ______

PHYSICAL DATE MUST BE AFTER: August 22nd, 2010

RETURN BY August 17th, 2011

PLEASE CIRCLE ONE SPORT:

BOYS: FOOTBALL SOCCER CROSS COUNTRY GOLF

GIRLS: FIELD HOCKEY SOCCER CROSS COUNTRY CHEER VOLLEYBALL

EMERGENCY CONTACT INFORMATION

This form is to be used by the athletic trainer or EMT on site, in the event of an emergency when you cannot be reached. Please complete, sign, and return this form to the school prior to the first practice of the athletic season.

Student’s Name: ______Birthdate: ______SS#: ______

Year of Graduation: ______Parent’s Name: ______

Address: ______City: ______Zip Code: ______

Phone #: ______Work #: ______Cell #: ______

Parent E-Mail Address: ______

Student Email: ______

In Case of an Emergency Contact: ______Phone #:______

(Other than Parent or Guardian)

Insurance Group: ______Policy #: ______

Primary Care Physician:______Phone #: ______

Allergies to Insect/Medications/Foods: NO/YES If Yes, please explain: ______

Do You Wear Glasses or Contacts NO/YES If Yes, please specify: ______

MEDICAL HISTORY QUESTIONNAIRE

1.  Please list any previous significant injuries your child has sustained: ______

______

2.  Have you had any prior surgery/surgeries? Please explain: ______

______

3.  Have you had any illnesses or injuries in the past year that have kept you from participating in athletics or school? If yes, please explain: ______

4.  Were you seen or treated by a doctor for the previous illness or injury? If yes, please name the physician and the diagnosis: ______

5.  Have you ever suffered from a concussion that was diagnosed by a physician or an Athletic Trainer? If yes, how many times and when: ______

6.  Have you ever suffered from a hit to the head where you have had a headache, nausea, dizziness, or lightheaded? If yes, how many times and when: ______

7.  Have you ever been diagnosed with any of the following; if you answer yes, please explain:

a.  Headache or Migraines: (NO/YES):______

b.  Learning Disability or Dislexia: (NO/YES): ______

c.  ADD/ADHD: (NO/YES): ______

d.  Depression, Anxiety, or any other psychiatric Disorder: (NO/YES): ______

e.  Seizure Disorder: (NO/YES): ______

8.  Have you been told by a doctor not to participate in a certain sport? If yes, please explain: ______

9.  Do you have asthma, diabetes, or heart related conditions that the Athletic Trainer should be aware of? Please explain: ______

______

10.  Do you have a medical condition that requires the use of medication? Please list all medications (asthma inhalers, insulin, epi-pens, etc) and explain: ______

______

11.  Are you required to wear protective devices such as knee, ankle or shoulder braces as directed by a physician? If yes, please explain: ______

12.  Are there any other medical conditions the Athletic Trainer should be aware of: ______

______

I hereby authorize in advance any necessary medical treatment required for my son/daughter while he/she is participating in Nauset Regional High School activities. This includes treatment by the certified athletic trainer on site, EMT’s, team physician (Dr. Andrew Judelson) and school physician (Dr. Nancy Golden), and emergency medical staff at area hospitals.

I have read the student athlete handbook at Nauset Regional High School and will abide by its guidelines and maintain good athletic citizenship while participating in athletics at Nauset Regional High School.

I herewith give permission for my son/daughter to participate in athletics and all trips and activities related to the athletic program.

I also give permission for my child ______to receive Tylenol (2 tablets, 650mg), Calcium carbonate (Tums) and/or Ibuprofen (2 tablets, 400mg). If at all possible over the counter medication should be given out at home prior to school and/or athletics.

NEW THIS YEAR MANDATED CONCUSSION COURSE INFORMATION:

I have been given information regarding head injuries and trauma that can be sustained while participating in athletics at Nauset Regional High School. It is understood that I will review the material given by the MIAA and Nauset Regional High School and complete the sports concussion awareness course on line @ www.nfhslearn.com. This is in accordance with the Commonwealth of Massachusetts Department of Public Health. All parents or guardians are required to do so prior to the start of the athletic season. It is further understood that as parent(s) or guardian(s) you acknowledge that you have successfully completed said course. Please print a copy of the completion certificate for your records.

Notice of risk: Student athletes and the student’s parent or guardian need to be aware that sports activities involve risk of injury. When an athlete practices, plays or participates in any sport, the activity can be dangerous. The student risks serious, permanent injury, and possibly death. Instructions given by the coach/certified athletic trainer regarding playing techniques, hitting techniques (where applicable), weight training, proper equipment usage and team rules must be followed.

X Student’s Signature: ______Date: ______

X Parent’s/Guardian’s Signature: ______Date: ______