Part A

Peekskill High School Varsity/JV Sports Health History

(Must be completed prior to the start of each season)

Student Name______Grade______School Year 2014/2015

To be completed in ink by parent or guardian. Incomplete forms will not be accepted. Every student who wishes to participate in sports must have this questionnaire and the parent permission form on file within 30 days prior to the start of each season.

Sport (circle one only)

Fall Sports Winter Sports Spring Sports

Football B or G Basketball Baseball

B or G Soccer Cheerleading Softball

Volleyball Wrestling B or G Track

Cheerleading B or G Bowling Lacrosse

B or G Cross Country B or G Winter Track Boys Tennis

Girls Tennis Boys Swimming B or G Golf

Girls Swimming

Please check Yes or No if your child has or had any of the following, include details below.

1. Asthma Yes_____No_____ Inhaler Used Yes_____No_____

2. Bee Sting Allergy Yes_____No_____ Epi-Pen Used Yes_____No_____

3. Allergies Yes_____No_____

4. Diabetes Yes_____No_____

5. My child wears: Braces Yes_____No_____

Eyeglasses/Contact Lenses Yes_____No_____

*I take full responsibility for their use during sports participation. Yes_____No_____

6. Heart Problems, high blood pressure, chest pain upon exertion, or murmur Yes_____No_____

7. Family history of any of the following: heart disease, death in a close relative younger than 50 years of age,

hypertrophic cardiomyopathy, long QT syndrome, or heart beat irregularities Yes_____No_____

8. History of “passing out”, fainting, or heat intolerance Yes_____No_____

9. History of serious injury, fracture, sprain, or ligament tear Yes_____No_____

10.Absence, injury, disease of kidney or ovary. Yes_____No_____

11.Absence of vision in either eye. Yes_____No_____

12.Ever been hospitalized Yes_____No_____

Details:______

Please list any medications your child is currently taking: ______.

Students who need to carry medication with them during sports participation (inhalers, insulin, diabetic supplies, Epi-pen, etc.) will need to have doctor’s orders and parental permission on file in the health office. These forms are available from the school nurse. No student who requires medication during sports participation will be cleared to play until these forms are submitted.

I attest that all these health history responses are correct and give permission for my child to have a complete physical examination by Dr. Michael Lasser, School Physician.

______

* PARENT/GUARDIAN SIGNATURE

NURSES SIGNATURE______DATE______