Office Use Only

School Physician Signature ________________________ School Nurse Signature ________________

Date Cleared ____________

Date of Last Sports Physical ____________

Scotia-Glenville C.S.D.

Interval Health History Form for Sports Participation

Prior to the start of tryout sessions or practice at the beginning of each season, a health history review for each student must be completed and turned in to the health office.

Part A- TO BE COMPLETED BY THE STUDENT

Student Name_________________________ Date of Birth_____________

Grade_______________ Age____________________

Sport________________________________

Part B-TO BE COMPLETED BY THE PARENT OR GUARDIAN

NOTE: "YES" to any of these questions does not mean automatic disqualification from participation in sports. However, it will require a review and approval by the school physician before the student can report to practice or tryouts.

HISTORY SINCE LAST HEALTH APPRAISAL

If the answer to any of the following questions is "YES," please describe the condition or situation that prompted your answer, giving the date and doctor clearance in Part C.

1. Any injuries requiring medical attention including, concussion or loss of consciousness? YES NO DATE______

2. Any illness lasting more than 5 days? YES NO DATE______

3. Currently taking medication or under the care of a physician for an active problem? YES NO DATE______

4. Any feelings of faintness, dizziness, fatigue, or chest pain after exercise or exertion? YES NO DATE______

5. Change in wearing glasses or contact lenses? YES NO DATE______

6. Any fractures or surgical procedures? YES NO DATE______

7. Any treatment in a hospital or emergency room? YES NO DATE______

8. Developed any allergies, asthma exercise induced asthma or reactions to medication? YES NO DATE______

9. Any chronic disease? (Diabetes, bleeding disorder Seizures?) YES NO DATE______

10. Problems with heat exhaustion/heat fatigue? YES NO DATE______

11. Absence of or the significant impairment of one of a pair of organs? (kidney, eye, ear, testicle)YES NO DATE______

12. Any history of sudden death in a family member under the age of 50? YES NO DATE______

13. For girls: Date of first menses? DATE ______

PART C- TO BE COMPLETED BY PARENT OR GUARDIAN

Describe the condition or situation that caused you to answer "YES" to any question in PART B. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PART D-PARENTAL PERMISSION

I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate in the athletic sport named in PART A of this form. The answers are correct as of this date and he/she has my permission to participate.

SIGNED___________________________________ DATE_____________

 

 

 

 

 

 

 

SCOTIA-GLENVILLE CENTRAL SCHOOL DISTRICT

SENIOR HIGH and JUNIOR HIGH HEALTH OFFICES

 

Dear Athletes and Parents/guardians of Athletes:

The State Education Department has modified the eligibility standards, NYSPHSAA, Inc. Constitution, Article II. (11), for sports physicals. They are as follows:

  • Physicals for participation in school sports may be scheduled at any time during the calendar year. The results of the physical shall be valid for a period of 12 months through the last day of the month in which the physical was conducted. Before participation in each sports season, the athlete’s parent/guardian must complete an interval health history form and have it reviewed by the school nurse in order for the 12-month physical to be valid. The purpose of the interval health history is to ensure that any health problems occurring since the last physical are identified and considered. The interval health history must be completed within 30 days of the start of the season.

    If the 12-month period for the physical expires during a sports season, participants may complete the season as long as a health history was conducted prior to the start of the season. Immediately following the last sanctioned tournament competition for that season, a new physical is required if the athlete is going to play another sport. Please remember that the sports season includes tryouts.

    •

    The school will still be offering sports physicals in the summer. Two dates are in June and one date is in August. The actual date and sign-ups are announced to all students at the beginning of May and several times before the end of the school year. In addition, posters are placed in various areas throughout the senior high school and junior high school with this information. All students having their sports physical through the school must be pre-screened by the school nurse prior to the date of their physical. The school nurses do not work during the summer, therefore all pre-screenings must be done prior to the last day of the school year.

     

    Kristine A. Barkley, RN Barbara Zabala, RN

    Senior High School Nurse Junior High School Nurse