southfieldpeds.com - MHSAA Sports Physical Form

MHSAA Sports Physical Form

Completed by Parent or Guardian or 18-Year-Old
Student Name:
Date of Birth:

MonthDayYear
Date
Doctor:
Doctor’s Phone:
Please enter a valid phone number.
Date of Exam:

MonthDayYear
Date
GENERAL QUESTIONS
Has a doctor ever denied or restricted your participation in sports for any reason?

YesNo
Do you have any ongoing medical conditions? If so, please identify below:

AsthmaAnemiaDiabetesInfections
Have you ever spent the night in the hospital or have you ever had surgery?

YesNo

HEART HEALTH QUESTIONS ABOUT YOU

	Yes	No
Have you ever passed out or nearly passed out DURING or AFTER exercise?
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Has a doctor ordered a test for your heart? (example, ECG/EKG, echocardiogram)
Do you get lightheaded or feel more short of breath than expected during exercise?
Do you have a history of seizure disorder or had an unexplained seizure?
Do you get more tired or short of breath more quickly than your friends during exercise?

Has a doctor ever told you that you have any heart problems? Check all that apply:

High blood pressureHeart murmurHeart infectionHigh cholesterolKawasaki disease

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

	Yes	No
Has anyone in your family had unexplained fainting, unexplained seizures or near drowning?
Does anyone in your family have a heart problem, pacemaker or implanted defibrillator?
Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?
Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?

BONE AND JOINT QUESTIONS

	Yes	No
Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or a game?
Have you ever had any broken or fractured bones, dislocated joints or stress fracture?
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches?
Do you regularly use a brace, orthotics or other assistive device?
Do you have a bone, muscle or joint injury that bothers you?
Do any of your joints become painful, swollen, feel warm or look red?
Do you have any history of juvenile arthritis or connective tissue disease?
Have you ever had an x-ray for neck instability or atlantoaxial instability (Down syndrome or dwarfism)?

MEDICAL QUESTIONS

	Yes	No
Do you cough, wheeze or have difficulty breathing during or after exercise?
Have you ever used an inhaler or taken asthma medicine?
Is there anyone in your family who has asthma?
Were you born without, or missing a kidney, eye, testicle (males), spleen or any other organ?
Do you have groin pain or a painful bulge or hernia in the groin area?
Have you had infectious mononucleosis (mono) within the last month?
Do you have any rashes, pressure sores or other skin problems?
Have you had a herpes or MRSA skin infection?
Do you have headaches or get frequent muscle cramps when exercising?
Have you ever become ill while exercising in the heat?
Do you or someone in your family have sickle cell trait or disease?
Have you had any problems with your eyes or vision or any eye injuries?
Do you wear glasses or contact lenses?
Do you wear protective eyewear such as goggles or a face shield?
Immunization History: Are you missing any recommended vaccines?
Do you have any allergies?
Have you ever had a head injury or concussion?
Do you have any concerns that you would like to discuss with a doctor?
Have you ever received a blow to the head that caused confusion, prolonged headache or memory problems?
Have you ever had numbness, tingling, weakness or inability to move your arms or legs after being hit or falling?
Have you ever had an eating disorder?
Do you worry about your weight?
Are you trying to or has anyone recommended that you gain or lose weight?
Are you on a special diet or do you avoid certain types of foods?

FEMALES ONLY (Optional)

	Yes	No
Have you ever had a menstrual period?
How old were you when you had your first menstrual period?
How many periods have you had in the last 12 months?

CURRENT-YEAR PHYSICAL = GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEARMEDICAL
PHYSICAL EXAMINATION & MEDICAL CLEARANCE: Completed by MD, DO, PA or NP - RETURN DIRECTLY TO PATIENT
EXAMINATION:
Height:
Weight:
Gender:

MaleFemale
BP:
Pulse:
Vision: R 20/
L 20/
Corrected:

YesNo

MEDICAL

	NORMAL	ABNORMAL
Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/Ears/Nose/Throat: Pupils, Equal Hearing
Lymph nodes
Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)
Pulses: Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)
Skin:
HSV:
Lesions suggestive of MRSA, tinea corporis
Neurologic

MUSCULOSKELETAL

	NORMAL	ABNORMAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
Functional Duck Walk

RECOMMENDATIONS:
I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities NOT crossed out below.

BASEBALL – BASKETBALL – BOWLING – COMPETITIVE CHEER – CROSS COUNTRY – FOOTBALL – GOLF – GYMNASTICS – ICE HOCKEYLACROSSE – SKIING – SOCCER – SOFTBALL – SWIMMING/DIVING – TENNIS – TRACK & FIELD – VOLLEYBALL – WRESTLINGXXXX-
Name of Examiner:
Date:

MonthDayYear
Date
Signature of Examiner:

Clear
(Check One):

MDDOPANP
EMERGENCY INFORMATION:

COMPLETED BY PARENT or GUARDIAN or 18-YEAR - OLD
Student:
Grade:
IN EMERGENCY (1):
IN EMERGENCY (2):
Drug Reactions:
Allergies:
PRE-PARTICIPATION PHYSICAL - CONSENT - INSURANCE

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR
Student Name:

First NameMiddle NameLast Name
Student Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:

MaleFemale
Age:
Date of Birth:

MonthDayYear
Date
Place of Birth (City/State):
School:
Grade:

6789101112
Father/Guardian Name:
Phone (home):
Please enter a valid phone number.
Phone (work):
Please enter a valid phone number.
Phone (cell):
Please enter a valid phone number.
Email Address: Parent/Guardian/18-Year-Old:
example@example.com
Mother/Guardian Name:
Phone (home):
Please enter a valid phone number.
Phone (work):
Please enter a valid phone number.
Phone (cell):
Please enter a valid phone number.
Email Address: Parent/Guardian/18-Year-Old:
example@example.com
STUDENT PARTICIPATION & PARENT or GUARDIAN or 18-YEAR-OLD CONSENT

The information submitted herein is truthful to the best of my knowledge. By my/my child’s signature below, I/we acknowledge that I/we have received concussion educational information that meets Michigan Department of Health and Human Services and MHSAA requirements.

Further, in consideration of my/my child’s participation in MHSAA-sponsored athletics, I/we do hereby agree, understand, appreciate, and acknowledge: that participation in such athletics is purely voluntary; that such activities involve physical exertion and contact and that there is inherent risk of personal injury associated with participation in such activities, which risk I/we assume; and that I/we agree to, and hereby waive any and all claims, suits, losses, actions, or causes of action against the MHSAA, its members, officers, representatives, committee members, employees, agents, attorneys, insurers, volunteers, and affiliates based on any injury to me, my child, or any person, whether because of inherent risk, accident, negligence, or otherwise, during or arising in any way from my/my child’s participation in an MHSAA-sponsored sport.

I/we understand that I am/we are expected to adhere firmly to all established athletic policies of my school district and the MHSAA. I/we hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the MHSAA of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for interscholastic athletics. My child has my permission to accompany the team as a member on its out-of-town trips.
Signature of STUDENT:

Clear
Date:

MonthDayYear
Date
Signature of PARENT or GUARDIAN or 18-YEAR-OLD:

Clear
Date:

MonthDayYear
Date
INSURANCE STATEMENT
Our son/daughter will comply with the specific insurance regulations of the school district.
The student-athlete has health insurance:

YESNO
If YES, Family Insurance Co:
Insurance ID #:
Additionally, I hereby state that, to the best of my knowledge, my answers to the medical history questions (see reverse) are complete and correct.
Signature of PARENT or GUARDIAN or 18-YEAR-OLD:

Clear
Date

MonthDayYear
Date
MEDICAL TREATMENT CONSENT: COMPLETED BY PARENT or GUARDIAN or 18-YEAR -OLD
I,Name , an 18-year-old, or the parent or guardian of Name , recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care.
Signature of PARENT or GUARDIAN or 18-YEAR-OLD:

Clear
Date

MonthDayYear
Date
Should be Empty:

MHSAA Sports Physical Form

GENERAL QUESTIONS

EXAMINATION:

EMERGENCY INFORMATION:

PRE-PARTICIPATION PHYSICAL - CONSENT - INSURANCE

INSURANCE STATEMENT

MEDICAL TREATMENT CONSENT: COMPLETED BY PARENT or GUARDIAN or 18-YEAR -OLD