Arlington Public Schools

REQUIRED MEDICAL and PERMISSION FORM

INTERSCHOLASTIC ATHLETICS

2008-2009 SCHOOL YEAR   Text Box: MIAA Rule 17 – All students must pass a physical examination within one year before participating in any sport…Any student who does not fulfill this requirement is considered ineligible. Contests in which the student participates in violation of this rule including FORGED PHYSICAL EXAMINATION must be forfeited.

 

 

 

 

 

 

PARENT/GUARDIAN – Please answer the following questions and SIGN RELEASE FORM

 

Student’s Name_________________________________Sex  M (  )   F(  )      YOG______  HR_________

Address_________________________      Town_____________________          ZIP_________________   

Birthdate__________Grade_______HomePhone  (    )____________Emergency Phone (   )____________

 

Parent(s) Names________________________(W)(   )  _______________    Cell(  ) __________________

Parent(s) E-mail _______________________________

Family Physician’s Name_______________________                  Tel. # (   ) _________________________

School attended last year__________________________________________________________________

 

 

STUDENT HEALTH INFORMATION

 

1.                  Food/Insect/Medication/ Allergies____________________________________________________

2.                  Current medications_______________________________________________________________

3.                  Eyeglasses/contacts/hearing aids other_________________________________________________

4.                  Other concerns____________________________________________________________________

________________________________________________________________________________

 

 

 

If the Nurse/Trainer/Athletic Director determines that an injury or condition has occurred that requires a medical clearance a RETURN TO PARTICIPATION form must be completed by the physician.

I hereby give my permission for my son/daughter to participate in the ARLINGTON HIGH SCHOOL ATHLETIC PROGRAM for the school year of 2008-2009.

              _____________________________________         ______________

                                                SIGNATURE OF PARENT                     DATE

   

***PARENT’S SIGNATURE WILL ALLOW PHYSICIAN TO COMPLETE SCHOOL PHYSICAL AS REQUIRED BY LAW FOR PARTICIPATION

 

OVER FOR PHYSICIAN’S EXAMINATION

               

MASSACHUSETTS SCHOOL HEALTH RECORD

Health Care Provider’s Examination

Name ________________________________________  Male  Female    Date of Birth:___________________

Medical History _________________________________________________________________________________________

_______________________________________________________________________________________________________

Pertinent Family History

 

Current Health Issues

Y          N

            Allergies:  Please list:  Medications _______________Food _________________ Other

      History of Anaphylaxis to ___________________ Epi-Penâ:   Yes   No

            Asthma:    Asthma Action Plan   Yes   No (Please attach)

            Diabetes:    Type I      Type II

             Seizure disorder:  ____________________________________________________________________________

             Other (Please specify) _________________________________________________________________________

Current Medications (if relevant to the student's health and safety)  Please circle those administered in school;  a separate medication order form is needed for each medication administered in school.

 

Physical Examination                                                                          Date of Examination:___________________________

Hgt: ________(_____%)  Wgt:_________(_____%)  BMI: _________(_____%)  BP: ________ 

(Check = Normal / If abnormal, please describe.)

 General ________________       Lungs __________________     Extremities _____________                          

  Skin __________________       Heart ___________________    Neurologic _____________      

  HEENT _______________         Abdomen _______________     Other __________________                       

  Dental/Oral ____________         Genitalia ________________

  Screening:                            (Pass) (Fail)                                                                          (Pass) (Fail)                                                                        (Pass) (Fail)

              Vision: Right Eye                                   Hearing: Right Ear                            Postural  Screening:       

                             Left Eye                                                     Left Ear                            (Scoliosis/Kyphosis/Lordosis)

                            Stereopsis        

 

Laboratory Results:          Lead _______  Date _______________     Other____________________________________

 

The entire examination was normal:   

 

Targeted TB Skin Testing:  Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors):  Date of PPD: ____;  Results: ____mm.

Referred for evaluation to:  _______________________________________       Low risk (no PPD done)

This student has the following problems that may impact his/her educational experience:

 Vision                                 Hearing                             Speech/Language                          Fine/Gross Motor Deficit

  Emotional/Social             Behavior                           Other

 Comments/Recommendations:_____________________________________________________________________

Y   N This student may participate fully in the school program, including physical education and competitive sports.  If no, please list restrictions:_____________________________________________________________________________________

 Y  N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System Certificate or other complete immunization record.

______________________________________________              ___________________________________________

Signature of Examiner   Circle: MD, DO, NP, PA     Date                               Please print name of Examiner.                                          

  ______________________________________________                             

Group Practice                                                      Telephone

___________________________________________________________________________________________________________

Address                                                           City                                                     State                       Zip Code      

Please attach additional information as needed for the health and safety of the student.                MDPH 05/31/05