Download Pre-Participation Physical for South Carolina High School Athletes

Pre-Participation Physical for South Carolina High School Athletes
York School District Number One
PLEASE PRINT
________________________________________________________________________________________
Last
First
M. I.
Preferred name __________________ Date of Birth ____________________
Sports ______________________
M
D
Y
______________________
Year of Graduation: ____________
2015-2016
Grade:
7
8
9
10
11
12
Sex:
M
F
Address _________________________________________________________________ Apt. _________________
City _________________ Zip Code ________
Email _________________________________________________
Parents/guardian phone _______________________ Work ______________________ Cell ____________________
Primary/family physician ______________________________________________ Phone _______________________
Emergency Contact _____________________________________________ Relation __________________________
Phone _________________________
Work Phone _________________________ Cell _______________________
Parents’ Permission/HIPAA Release/Acknowledgement of Risk for Athletic Participation
As the parents or legal guardian of the above named student-athlete, I give my consent for his/her participation in athletic events and
the physical evaluation for that participation. I understand that this is simply a screening evaluation and not a substitute for regular
health care. I also grant permission for treatment deemed necessary for a condition arising during participation of these events,
including medical or surgical treatment that is recommended by a medical doctor. I grant permission to nurses, athletic trainers, and
coaches as well as physicians or those under their direction who are part of athletic injury prevention and treatment, to have access to
necessary medical information/records/documentation. I know that the risk of injury to my child/ward comes with participation in
sports and during travel to and from play and practice. I have had the opportunity to understand the risk of injury during participation
in sports through meetings, written information, or by some other means. My signature below indicates that to the best of my
knowledge, my answers to the above questions and on the Patient Medical History form are complete and correct. I understand that
the data acquired during these evaluations may be used for research purposes.
I give consent for the head athletic trainer at YCHS to release information regarding my child’s medical history and/or records that
pertain directly to athletic participation at YCHS. This information may be requested by agents of any amateur or professional athletic
organization, college or university, or insurance company. I also grant permission for the YCHS athletic trainer to receive medical
information from any medical practice concerning my child’s athletic injury information for the continuity of care. This information
may be transmitted via telephone, personal interview, electronic mail, postal service, fax or other form of media not listed here. This
permission will be in effect from August 1, 2015 – July 31, 2016.
By signing this document I/we acknowledge that we have received, read, and understand the patient history form,
information concerning school insurance, and the York School District Concussion Policy, and we have been afforded the
opportunity to ask any questions pertaining to the history and concussion policy.
PRINT Name, Parent/Legal Guardian _____________________________________________________________________
Parent/Legal Guardian Signature _________________________________________________ Date __________________
Student Signature ___________________________________________________________________________________
Patient Medical History for Pre-Participation Physical
Name ___________________________________
GENERAL QUESTIONS - Circle “Yes” or “No” for each question.
YES
NO
1. Has a doctor ever denied or restricted your participation in sports for any reason?
YES
NO
2. Do you have any ongoing medical conditions? If so, please identify
YES
NO
3. Have you ever spent the night in the hospital?
YES
NO
4. Have you ever had surgery?
HEART HEALTH QUESTIONS ABOUT YOU - Circle “Yes” or “No” for each question.
YES
NO
5. Have you ever passed out or nearly passed out DURING or AFTER exercise?
YES
NO
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
YES
NO
7. Does your heart ever race or skip beats (irregular beats) during exercise?
YES
NO
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
Other: ____________________________________________
YES
NO
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
YES
NO
10. Do you get lightheaded or feel more short of breath than expected during exercise?
YES
NO
11. Have you ever had an unexplained seizure?
YES
NO
12. Do you get more tired or short of breath more quickly than your friends during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY - Circle “Yes” or “No” for each question.
YES
NO
13. 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)?
YES
NO
14. 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?
YES
NO
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
YES
NO
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
BONE AND JOINT QUESTIONS - Circle “Yes” or “No” for each question.
YES
NO
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
YES
NO
18. Have you ever had any broken or fractured bones or dislocated joints?
YES
NO
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
YES
NO
20. Have you ever had a stress fracture?
YES
NO
21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down
syndrome or dwarfism)
YES
NO
22. Do you regularly use a brace, orthotics, or other assistive device?
YES
NO
23. Do you have a bone, muscle, or joint injury that bothers you?
YES
NO
24. Do any of your joints become painful, swollen, feel warm, or look red?
YES
NO
25. Do you have any history of juvenile arthritis or connective tissue disease?
MEDICAL QUESTIONS - Circle “Yes” or “No” for each question.
YES
NO
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
YES
NO
27. Have you ever used an inhaler or taken asthma medicine?
YES
NO
28. Is there anyone in your family who has asthma?
YES
NO
29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
YES
NO
30. Do you have groin pain or a painful bulge or hernia in the groin area?
YES
NO
31. Have you had infectious mononucleosis (mono) within the last month?
YES
NO
32. Do you have any rashes, pressure sores, or other skin problems?
YES
NO
33. Have you had a herpes or MRSA skin infection?
YES
NO
34. Have you ever had a head injury or concussion? If yes, how many: ______
Month/year: ____________________________
YES
NO
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
YES
NO
36. Do you have a history of seizure disorder?
YES
NO
37. Do you have headaches with exercise?
YES
NO
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
YES
NO
39. Have you ever been unable to move your arms or legs after being hit or falling?
YES
NO
40. Have you ever become ill while exercising in the heat?
YES
NO
41. Do you get frequent muscle cramps when exercising?
YES
NO
42. Do you or someone in your family have sickle cell trait or disease? Relation ________________________________________
YES
NO
43. Have you had any problems with your eyes or vision?
YES
NO
44. Have you had any eye injuries?
YES
NO
45. Do you wear glasses or contact lenses?
YES
NO
46. Do you wear protective eyewear, such as goggles or a face shield?
YES
NO
47. Do you worry about your weight?
YES
NO
48. Are you trying to or has anyone recommended that you gain or lose weight?
YES
NO
49. Are you on a special diet or do you avoid certain types of foods?
YES
NO
50. Have you ever had an eating disorder?
YES
NO
51. Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY - Circle “Yes” or “No” for each question.
YES
NO
52. Have you ever had a menstrual period?
YES
NO
53. How old were you when you had your first menstrual period?
YES
NO
54. How many periods have you had in the last 12 months? _______________________
Pre-Participation Physical Examination
Height _________ inches
Name _____________________________________________
Weight ________ pounds
Blood Pressure: Right
____________/ __________
Vision: L 20/ ______
R 20/ ______
OR
Pulse, R ________
L _________
Left _____________/ ______________
Vision, corrected: L 20/ ______
Medical
OR
R 20/ ______
Normal
Contacts
Glasses
Abnormal Findings
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate,
pectus excavatum, arachnodactyly, arm span > height,
hyperlaxity, myopia, MVP, aortic insufficiency
EENT – pupils equal, hearing
Lungs
Heart
Murmurs (auscultation standing, supine, +/Valsalva
Abdomen
Skin – HSV, lesions suggesting MRSA, tinea
corporis
Lymph nodes
Genitourinary (males only)
Musculoskeletal
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/toes
Functional – duck walk, single leg hop
Declined ________
Normal
Abnormal Findings
Physician – please check the box that applies:
CLEARED for all sports EXCEPT
________________________________________________________
NEEDS FURTHER EVALUATION FOR _____________________________________________________
Secondary Clearance Physician signature
NOT CLEARED DUE TO
Name of Physician or Practice
_______________________________________________________________
______________________________________________________________
_____________________________________________________________________________
Address ___________________________________________________________________
Zip ________________________
Signature _________________________________________________, MD or DO
___________________________
Phone
Printed name _______________________________________________________________________________________________
Date of Physical ____________________________
Date YCHS Sports Medicine ___________________________
Insurance Information: YCHS Athletic Department provides an All Sports policy/coverage on all athletes at York Middle School and
York Comprehensive High School. This coverage is secondary to the insurance listed below. The YCHS policy is primary if you do not
have any other insurance or if you have Medicaid. Secondary insurance: pays after the personal insurance has paid
Yes
No
Do you have health insurance? If yes, see below.
Yes
No
Do you have Medicaid?
Yes
No
Does your insurance require you to get a referral from your family physician prior to seeing a
specialist (orthopaedist, neurologist, general surgeon, etc.)
If yes, Medicaid number: _______________________________
Name of insurance company __________________________________________________________________________
Mailing address ___________________________________________________________________________________
Street/PO Box
City
State
Zip
Insured’s name ___________________________________________________________________________________
Policy number ______________________________________
Group number _________________________________
York School District Concussion Policy
York School District One is committed to the prevention, identification, evaluation and management of concussions. Per recent
concussion recommendations, the district requires that any student-athlete who exhibits signs, symptoms or behaviors consistent with
a concussion be removed from practice or competition and be evaluated by an appropriate health-care professional who has experience
in the evaluation and management of concussions. Those student-athletes diagnosed with a concussion shall not return to activity for
the remainder of that day. Medical clearance shall be determined by a licensed physician or their designee according to the concussion
management plan.
What is a Concussion, also known as Traumatic Brain Injury or Closed Head Injury?
A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force
transmitted to the head which causes a change in mental status. Concussions can also result from hitting a hard surface as the ground,
ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat or ball.
Signs and Symptoms
Observed by Coaching staff
Appears dazed or stunned
Confused about assignment or position
Forgets plays
Unsure of game, score or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Show behavior or personality changes
Can’t recall events before hit or fall
Can’t recall events after hit or fall
Reported by student athlete
Headache or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy or groggy
Concentration or memory problems
Confusion
Does not “feel right”
Education and Acknowledgement
The NCAA Concussion Fact Sheet information has been included as a part of the district’s “pre-participation physical” packet. Before
being allowed to participate in any sport, all York School District One student-athletes and their parents must read this document and
sign the concussion awareness statement acknowledging that they have read and understand the information and their responsibility to
report their injury and illnesses to a staff certified athletic trainer or coach, including the signs and symptoms of a concussion.
York School District One students involved in organized, contact sports specifically football, wrestling, soccer, volleyball, cheerleading,
basketball, baseball, and softball, upon return of their physicals, will be required to complete a baseline ImPACT test with one of the
district’s certified assessors before their season begins. One of the staff certified athletic trainers or a certified coach will talk with
the teams about concussions and answer any questions before the season starts.
All staff certified athletic trainers and coaches will be required to comply with the concussion policy that is in place, as well as
complete the CDC Concussion Course in accordance with SCHSL rules.
Concussion Management Plan
Any student-athlete experiencing any of the above noted signs and/or symptoms should report to a staff certified athletic trainer or
coach as soon as possible. Any athlete exhibiting signs, symptoms, or behaviors consistent with a concussion shall be removed from
athletic activities by a certified athletic trainer (or coach in the absence of the certified athletic trainer) and evaluated by an
appropriate health-care professional as soon as possible.
The South Carolina High School League has determined the following health care professionals to be the appropriate health-care
professionals:

Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

Nurse Practitioner

Physician’s Assistant (PA)

Certified Athletic Trainer (ATC and/or SCAT)
Only SC High School League designated health care professionals (listed above) will be used to determine the status of the
concussed student/athlete.
No student-athlete will return to play the same day they sustain a concussion or exhibit ANY concussion symptoms until cleared by the
appropriate medical professionals.
When a student-athlete sustains a concussion, the following people will be notified and will receive instructions on how to take care of
that student-athlete:

Parents

Head Coach

Student-Athlete’s teachers (due to cognitive concentration and focus and possible accommodations that need be made)
When a student-athlete sustains a concussion, his/her parent will be contacted as soon as possible and both parent and student-athlete
will be further educated in concussion management. The “Athlete Information” portion of the SCAT2 will be provided to the
parent/student-athlete along with information from the CDC for parent awareness of traumatic brain injury.
When a student-athlete sustains a concussion, they will be required to complete a SCAT2 with one of the district’s certified assessors
as soon as possible. Each athlete with a possible concussion will be required to see a doctor within 12 hours to rule out any underlying
problems.
After the first evaluation and SCAT2 by the certified athletic trainer, and being seen by a physician, the student-athlete will be
required to report to the certified athletic trainer daily to do a symptom check (first portion of SCAT2). The remaining portion of the
SCAT2 will be performed at the following intervals until they are completely asymptomatic and score at least 85% or the ImPACT postinjury results are at or near baseline data.



Within 24 hours of injury
72 hours post-injury and every other day after until asymptomatic and score of at least 90% on SCAT2
ImPACT post-injury testing conducted once asymptomatic; possibly before if still symptomatic
Graduated Return to Play Protocol for the Concussed Athlete
The student-athlete will begin the graduated return to play protocol when cleared by the physician, asymptomatic (no symptoms
present), and passes the SCAT2 or ImPACt as determined by the athletic trainer.




Day One:
Day Two:
Day Three:
Day Four:
Light exercise
Intense exercise with sport specific drills
Non-contact drills at practice plus conditioning
Full contact practice
If the student-athlete becomes symptomatic during any stage of the return to play protocol, after 24 hours, they will return to day
one and repeat the process until they are completely asymptomatic.
Important injury information – all doctor visits that result in the athlete being removed temporarily from activity MUST BE IN
WRITING from the doctor’s office. In order for the athlete to return to activity ANOTHER WRITTEN NOTE from the
doctor’s office must be presented to the athletic trainer(s) or the coach. In short, if the doctor says the athlete cannot play,
then the doctor must give the approval to return to action.
Abbreviated Protocol for Return to Activity – the above protocol “in a nutshell”
1. Medical doctor clearance in writing
2. Be asymptomatic as determined by the certified athletic trainer, SCAT2, and/or ImPACT
3. Complete graduated return to play
York School District One Concussion Awareness Statement
My signature on the demographic/parents’ permission page indicates that you have received, read and understand the information
provided to me about concussions on the York School District Concussion Policy and the CDC Concussion Fact Sheet. I understand that
a concussion is a brain injury and there are consequences, including possible death, if I try to hide this injury. By signing the statement
found on the front of this document I understand that it is my responsibility to report any symptoms I may be having as soon as
possible to a staff certified athletic trainer or my coach in the absence of a staff certified athletic trainer.