Part A - TO BE COMPLETED BY THE SCHOOL HEALTH OFFICE

Student______________________________________________ DOB___/___/___ Age______Grade_______

Sport________________________Level (check) 1 Var 1 Modified

1 JV 1

Date of last physical____/___/___ Limitations 1 Yes 1 No

Part B - TO BE COMPLETED BY THE PARENT OR GUARDIAN

Any "Yes" answers will need to be explained in Part C

1. Any changes since last Health History ? 1 Yes 1 No

2. Any Injuries requiring Medical Attention? 1 Yes 1 No

3. Any Illness lasting more than 5 (five) days? 1 Yes 1 No

1 Yes 1 No

5. Any change in wearing glasses or contact lens? 1 Yes 1 No

6. Any head injury or loss of consciousness? 1 Yes 1 No

7. Any surgery or fractures? 1 Yes 1 No

8. Any treatment in a hospital, clinic or Emergency Rm? 1 Yes 1 No

9. Any new allergies? 1 Yes 1 No

10. Any chronic illness or disease? 1 Yes 1 No

11. Presently taking medicine or under a physicians care? 1 Yes 1 No

PART C - TO BE COMPLETED BY A PARENT OR GUARDIAN

Describe the condition or situation that caused any questions in Part B that were "Yes"

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Part D - Parental Permission

Signed___________________________________________________________ Date: ___/___/___

Part E - To be Completed by the School Health Office

Sports Participation (check): 1 Approved 1 Referred to School Physician

Signed_________________________________________School Nurse Date ___/___/___

1 Requalified 1 Disqualified

Signed ________________________________________School MD Date ___/___/___

I, the undersigned, clearly understand that these questions are asked in order to decide if my child can safely participate on the sport team

named in Part A of this form. The answers are correct as of this date and he/she has my permission to participate.

Please Return to the School Health Office

Chateaugay Central School - Interval Health History

Sports Participation

Prior to the start of tryouts, practice or at the beginning of each new sport session, a health history review for each athlete must be conducted, unless the

student has received a full medical exam within 30 days of the start of the season.

NOTE: "Yes" to any of these questions does not mean automatic disqualification from the sport indicated in Part A above. However, it will

require review and approval by the school physician before the student can report to the practice or tryouts. The answers to the questions

on this form will be held in the School Health Office and will be kept strictly confidential.

4. Any feeling of faintness, dizziness or fatigue after

exercise or exertion?