SOUTH BURLINGTON HIGH SCHOOL
SPORTS HEALTH QUESTIONNAIRE
TO BE
COMPLETED, SIGNED BY PARENT/LEGAL GUARDIAN AND STUDENT
AND
RETURNED TO THE ATHELTIC MEDICINE OFFICE BEFORE EACH
SPORTS SEASON
NAME:__________________________
SPORT: ___________________ DATE: ___/___/___
BIRTH DATE:
____/____/____ SEX: M_____
F_____ GRADE:________
ADDRESS:
___________________________________________________________________
TELEPHONE:_______________
PARENT/GUARDIAN NAME: _____________________
If you have had any injury or illness since your last physical that has lasted longer than a week in the six months prior to the date of this form, then you will also need a statement from your physician about this condition with his/her assessment regarding your ability to participate in the sport.
Name
of Physician: _______________________ Name of Health Care Facility:
_______________________
Please answer
the following questions, and explain below any answered “Yes”. YES NO
Have you ever …..
1.
Been
told you could not participate in sports in the last 2 years? ___ ____
2.
Been
told you have had a concussion? Unconscious or lost memory from a blow to the
head? ___ ____
3.
Had
a fracture or dislocation? Recurrent back pain? ___
____
4.
Had
a knee, ankle or shoulder sprain or back injury lasting more than 1 week? ___
____
5.
Had
any other injuries/illness that caused you to miss physical activity for more
than 1 week? ___
____
6.
Had
surgery of any kind? Been hospitalized for an operation or overnight stay? ___
____
7.
Felt
faint/dizziness or fainted during exercise? ___
____
8.
Experienced
chest pains, irregular heart beats, heart murmur or been diagnosed with a heart disorder/disease?
___ ____
9.
Been
or are you now under medical care for heart disease, diabetes, bleeding
tendencies,
seizures, kidney disease? ___
___
10.
Have
any of your grandparents, parents, siblings suffered a heart attack before age
50? ___ ____
Do you ….
11.
Take any medications every day or other medications regularly?
___ ____
12.
Have any allergies? ___ ____
13.
Have asthma or exercised-induced asthma? Shortness of breath/wheezing with
exercise? ___
____
14.
Have an impairment or loss of a paired organ (eyes, kidney, testicle, lung,
etc)? ___ ____
15.
Have a condition that requires any special equipment for participation in
sports
(pads, braces, eye protection)? ___ ____
If
any of the above questions are answered "YES", please explain below:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
I HAVE READ THE ABOVE QUESTIONS AND ANSWERED THEM TO THE VERY BEST OF
MY KNOWLEDGE.
PARENTAL/GUARDIAN PERMISSION
By its nature, participation in interscholastic
athletics includes risk of injury which may range in severity from minor to
disabling to even death. Although
serious injuries are not common in supervised school athletic programs, it is
impossible to eliminate the risk.
Participants can and have the responsibility to help reduce the chance of injury. Participants must obey all safety rules, report all physical
problems to their coaches and/or Certified Athletic Trainer, follow a proper
conditioning program, and inspect their own equipment daily.
By signing this permission form, we acknowledge that
we have read the above information.
Parents or students who do not wish to accept the risks described in
this warning should not sign this permission form.
“I hereby give
my consent for the above-named student,
1.
To participate in
Vermont Principals' Association approved athletic programs as a representative
of South Burlington High School in the athletic activity named above.
2.
To accompany any
school team of which he/she is a member on its local or out-of-town trips;
3.
To have my child
examined or receive emergency medical care by school officials, physician or
Certified Athletic Trainer which may become reasonably necessary in the course
of such athletic activities or travel.
4.
To have individual
student names and sports photos published on the SBHS athletic webpage.
I further agree not to hold the school or anyone
acting in its behalf responsible for any injury occurring to the above-named
student in the proper course of such athletic activities or travel.”
Parent/Guardian Signature:___________________________________________
“I have read the foregoing and will abide by the
principles and regulations contained therein.”
Student’s Signature: _____________________________________________
(Vermont Principals' Association requires proof of insurance to
participate)
o My son/daughter is covered under our own insurance policy.
Policy Number: ______________________Company:
________________________
o My son/daughter will or has
purchased the school accident insurance policy, and paid extra premiums, if
necessary, for participation. This
policy will give her/him coverage during any school activities.