Updated July 2013

OSSAA PHYSICAL EXAMINATION AND PARENTAL CONSENT FORM

PLEASE PRINT DATE OF EXAM____________________________

Name ________________________________________________________________ Sex _________ Age ________________ Date of Birth ___________________________________

Grade _______________ School ____________________________________________________________________________ Sport(s) _______________________________________

Address ________________________________________________________________________________________________________ Phone _________________________________

Personal physician _______________________________________________________________________________________________ Phone _________________________________

In case of emergency, contact: Name _______________________________________________________________________________________________________________________

Relationship _____________________________________________________________ Phone (H) ________________________________ (W) ________________________________

Explain Yes answers below. Circle questions you dont know the answers to.
YES NO YES NO
1. Have you had a medical illness or injury since your last check
up or sports physical?





Do you have an ongoing or chronic illness?


2. Have you ever been hospitalized overnight?


Have you ever had surgery?


3. Are you currently taking any prescription or nonprescription
(over-the-counter) medications or pills or using an inhaler?





Have you ever taken any supplements or vitamins to help you
gain or lose weight or improve your performance?





4. Do you have any allergies (for example, to pollen, medicine,
food, or stinging insects)?





Have you ever had a rash or hives develop during or after
exercise?





5. Have you ever passed out during or after exercise?


Have you ever been dizzy during or after exercise?


Have you ever had chest pain during or after exercise?


Do you get tired more quickly than your friends do during
exercise?





Have you ever had racing of your heart or skipped heartbeats?


Have you had high blood pressure or high cholesterol?


Have you ever been told you have a heart murmur?


Has any family member or relative died of heart problems or
of sudden death before age 50?





Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?





Has a physician ever denied or restricted your participation in
sports for any heart problems?





6. Do you have any current skin problems (for example, itching,
rashes, acne, warts, fungus, or blisters)?





7. Have you ever had a head injury or concussion?


Have you ever been knocked out, become unconscious, or lost
your memory?





Have you ever had a seizure?


Do you have frequent or severe headaches?


Have you ever had numbness or tingling in your arms, hands,
legs, or feet?





8. Have you ever become ill from exercising in the heat?


9. Do you cough, wheeze, or have trouble breathing during or
after activity?





Do you have asthma?


Do you have seasonal allergies that require medical treatment?


Do you or does someone in your family have sickle cell trait or
disease?

10. Do you use any special protective or corrective equipment or
devices that arent usually used for your sport or position (for
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)?









11. Have you had any problems with your eyes or vision?


Do you wear glasses, contacts, or protective eyewear?


12. Have you ever had a sprain, strain, or swelling after injury?


Have you broken or fractured any bones or dislocated any
joints?





Have you had any other problems with pain or swelling in
muscles, tendons, bones, or joints?





If yes, check appropriate box and explain below.
Head Elbow Hip
Neck Forearm Thigh
Back Wrist Knee
Chest Hand Shin/calf
Shoulder Finger Ankle
Upper arm Foot
13. Do you want to weigh more or less than you do now?


Do you lose weight regularly to meet weight requirements for
your sport?





14. Do you feel stressed out?


15. Record the dates of your most recent immunizations (shots) for:
Tetanus _________________ Measles _________________________
Hepatitis ________________ Chickenpox ______________________

Explain Yes answers on a separate sheet.

The above information is correct to the best of my knowledge. I hereby give my informed consent for the above-mentioned student to participate in activities. I understand
the risk of injury in athletic participation. If my son/daughter becomes ill or is injured, necessary medical care can be instituted by physicians, coaches, trainers or other
personnel properly trained. I further acknowledge and consent that, as a condition for participating in activities, identifying information about the above-mentioned student
may be disclosed to OSSAA in connection with any investigation or inquiry concerning the students eligibility to participate an/or any possible violation of OSSAA rules.
OSSAA will undertake reasonable measure to maintain the confidentiality of such identifying information, provided that such information has not otherwise been publicly
disclosed in some manner.

Signature of parent/guardian_____________________________________Signature of Athlete_________________________________________Date__________________



PREPARTICIPATION PHYSICAL EVALUATION


PLEASE PRINT DATE OF EXAM _____________________________

Name __________________________________________________________Date of Birth ______________________________________

Height _______ Weight _______ Body fat (optional) _____% Pulse_______ BP _______/_______

.

Vision: R 20/_______ L 20/________ Corrected Y / N Pupils: Equal ______ Unequal ______



MEDICAL Normal Abnormal Findings
Appearance
Eyes/Ears/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia (male only)
Skin
MUSCULOSKETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot

CLEARANCE

( ) Cleared

( ) Cleared after completing evaluation/rehabilitation for: ________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

( ) Not cleared for: _________________ Reason: __________________________________________________________
___________________________________________________________________________________________________

Recommendations: ___________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Name & Title of Examiner (Print/Type) _____________________________________ Date _________________________

Address _____________________________________________________________Phone __________________________

Signature of Examiner ______________________________________________________