DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH * THE CITY OF NEW YORK * BOARD OF EDUCATION INTERSCHOLASTIC * SPORTS EXAMINATION * -CONFIDENTIAL

0515'-

I.D.I

NAME:

ADDRESS;

SCHOOL: HOMEROOM:

PART 1 to be flied In Student's Health folder

BOROUGH:

GRADE:

TELEPHONE: SPORT:

DATE OF BIRTH: EMERGENCY TELEPHONE:

SPORT:

PARENTAL PERMISSION: I have reviewed the STUDENTS MEDICAL H!STORY $ection below and I

agree with the answers. I give permission for

to have a

physical examination. I understand that completion of the Maturation Index is optional

SIGNATURE

DATE:

RELATIONSHIP

*********************************************************************************

CLINICIAN'S RECOMMENDATIONS

Based on my review of the history and physical examination as noted below and on the back of this fornI, and review of the guidelines on P. 4, this student:

(1) May participate in the following sports: DRAW A LINE THROUGH ANY SPORTS TO BE OMITTED:

CONTACT

Football Baseball Basketball Soccer

Hockey Wrestling Lacrosse Softball

ENDURANCE

Gymnastics Swimming Track & Field

Cross-country Tennis

Volleyball Handball

Fencing

OTHER DATE OF lAST TETANUS BOc:Xrn:R

(2) Special conditions for participation (e.g., pre-exercise medication or protective equipment), if any:

DATE TELEPHONE:

REGISTRY'

SIGNATURE; NAME: (PRINT)

ADDRES- S:

~K:IAN)

;,\;1(1'"

STUDENT'S MEDICAL HISTORY

(Tobe filled out by student and parent) Has anyone in your family under age

45 died suddenly?

Yes 0 No 0

Clinician's Comments

Have you ever had: Concussion or been knocked oul? Fainting? Heat Stroke? Epilepsy, seizures, or fils? Head or neck injury? Very bad vision in one or both eyes?

Do you wear glasses, contacts, other?

Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0

No 0 No 0 No 0 No 0 No 0 No 0 No 0

Have you ever had: Hearing loss or deafness?

Yes 0 No 0

25-1190.00.5 10/~(REV.8/881

PART 1 -STUDENT'S HEALTH FOLDEF

STUDENT'S MEDICAL HISTORY (To be filled out by student and parent)

Perforated ear drum or "tubes" in ears? Draining ears?

Yes 0 Yes 0

Have you ever had: Sinus problems or hay fever Braces or removable false teeth

Yes 0 Yes 0

Have you ever had: Any broken bones? Dislocation or other serious problem? Serious foot problem?

Back injury or frequent backaches? Ankle or knee Injury or problem? Other joint problems?

Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0

Do you have a hernia?

Boys: Any problems with testicles? Girls: Any menstrual problem?

Age at first menstrual period? Do you miss school because of your period?

Yes 0 Yes 0 Yes 0

Yes 0

Have you ever had: Diabetes? Single illness for more than 10 days?

Any operations? Easy bruising or bleeding tendency? Anemia Asthma? Bee sting allergy? Other allergies (food or medicine) Heart trouble or murmurs? High blood pressure? Cough lasting more than 3 weeks? Chest pain or faintness with exercise?

Kidney problems? Skin infections?

Yes 0 Yes 0

Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0

Yes 0 Yes 0

Do you take any medicines?

Yes 0

Do you smoke?

Yes 0

Have you ever been told not to play any sport

because of your health?

Yes 0

No 0 No 0

No 0 No 0

No 0 No 0 No 0 No 0 No 0 No 0

No 0 No 0 No 0

No 0

No 0 No 0 No 0 No 0 No 0 NQ 0 No 0 No 0 No 0 No 0 No 0 No 0 No 0 No 0 No q No 0

No 0

CONTINUED: Clinician's Comments

PHYSICAL EXAMINATION

A complete physical examination for all students is recommended. will not disqualify a student from participation.

Omission of the Maturation Index

Height VisionUncorrecred:

Weight

L201

..

R20/-

Pulse

Skin

Eyes ENT Mouth & Teeth Neck Cardiovascular Lungs, Chest Spine Abdomen Genitalia (Hernia) Maturation Index

Extremities

Orthopedic Neuromuscular

Normal

Other tests, if done (Lab, ECC,etc.):

Assessment:

Blood Pressure

Corrected: L 201

R 201

Abnonnal

Comments

Plan:

DEPARTMENT OF HEALTH * THE CITY OF NEW YORK * BOARD OF EDU(:ATION INTERSCHOlASTIC * SPORTS EXAMINATION * -CONFIDENTIAL

OSIS#

I.D.#-

,4,;,[ PART2 C:;O:;S I

NAME:

SCHOOl.:

~H:

ADDRESS:

HOMEROOM:

GRADE:

TELEPHONE: SPORT:

DATE OF BIRTH: EMERGENCY TELEPHONE:

SPORT:

PARENTAL PERMISSION: I have reviewed the STUDENTS MEDICAL HISTORY sectilon below and I

agree with the answers. I give permission for

to have a

physical examination. I understand that completion of the Maturation Index is optional.

SIGNAllJRE

DATE: ************************************************************

RELATIONSHIP

CLINICIAN'S RECOMMENDATIONS

Based on my review of the history and physical examination as noted below and on the back of this foml, and review of the guidelines on P. 4, this student:

(1) May participate in the following sports: DRAW A LINE THROUGH ANY SPORTS TO BE OMITTED:

CONTACT

Football Baseball Basketball Soccer Hockey Wrestling Lacrosse Softball

ENDURANCE

Gymnastics Swimming Track & Field

Cross-country Tennis Volleyball Handball Fencing

OTHER DATE OF LAST TETANUS ~

(2) Special conditions for participation (e.g., pre-exercise medication or protective equipment), if any:

DATE TELEPHONE:

SIGNATURE: NAME: (PRINT) ADDRESS:

k:UNK:IAN)

AEGISTRY#

PART 2 -COACH'S COpy ********************************************************************i'

GUIDELINES FOR DISQUALIFYING CONDITIONS FOR SPORTS PARTICIF'ATION

CONDITIONS

CONTACT NONCONTACTENDURANCE

Acute Infections:

Respiratory, genitourinary, infectious mononucleosis,

hepatitis, active rheumatic fever, active tuberculosis

boils furuncles, impetigo

'X

X

Obvious physical immaturity in comparison with other

competitors

X

Obvious growth retardation

X

Hemorrhagic disease

Hemophilia, purpura, and other bleeding tendencies

X

Diabetes, inadequately controlled

X

X

Jaundice, whatever cause

X

X

OTHER X

X X

EYES

Absence or loss of function of one eye

X

Severe myopia, even if correctable

X

EARS Significant impairment

RESPIRATORY Tuberculosis (active or under treatment Severe pulmonary insufficiency

X

X

X

X

X

X

X

CARDIOVASCULAR

Rheumatic heart disease coaretation of aor1a, cyanotic

hear1 disease, recent carditis of any etiology

X

X

X

Hypertension on organic basis

X

X

X

Significant residual hear1 disease following heart surgery

for congenital or acquired heart disease

X

X

X

LIVER, enlarged

X

SPLEEN, enlarged HERNIA, Inguinal or femoral

X

X

X

MUSCULOSKELETAL

Symptomatic inflamation

X

X

X

Functional inadequacy incompatible with the contact or

skill demand of the sport

X

X

NEUROLOGICAL

History or symptoms of previ06s'~rious head trauma or

repeated concussions

X

Convulsive disorder not"completely

controlled by

medication

X

X

Previous Surgery on head or spine

X

X

RENAL Absence of one kidney Renal disease

X

X

X

X

GENITALIA

Absence of one testicle

X

Undescended testicle

X

*The Guidelines for Disqualifying conditions for Sports Participation listed on this form serve only as recommendations to the examining physician. The decision as to whether a student is qualified to participate should be individualized. In case of differences IDfinterpretation the decision of the school physician has precedence. Appeals may be requested through established procedures.

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