Physician Release For Wrestler To Participate With Skin Lesion(S) printable pdf download

PHYSICIAN RELEASE FOR WRESTLER

TO PARTICIPATE WITH SKIN LESION(S)

Name: _____________________________________________

Date of Exam: ___ / ____ / ___

Mark Location AND Number of Lesion(s)

Diagnosis __________________________________________

__________________________________________________

Location AND Number of Lesion(s) ______________________

__________________________________________________

Medication(s) used to treat lesion(s): ______________________

__________________________________________________

Date Treatment Started: ___ / ____ / ____

Form Expiration Date: ___ / ____ / ____

Earliest Date may return to participation: ____ / ____ / ____

Provider Signature ________________________________________ Office Phone #: ______________________

Provider Name (Printed or Typed) _______________________________________________________________

(M.D. or D.O.)

Office Address_______________________________________________________________________________

Note to Appropriate Health Care Professionals.: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.). Please

familiarize yourself with NFHS Rules 4-2-3, 4-2-4 and 4-2-5 which states:

“ART. 3 . . . If a participant is suspected by the referee or coach of having a communicable skin disease or any other condition that makes

participation appear inadvisable, the coach shall provide current written documentation as defined by the NFHS or the state associations,

from an appropriate health-care professional stating that the suspected disease or condition is not communicable and that the athlete’s

participation would not be harmful to any opponent. This document shall be furnished at the weigh-in for the dual meet or tournament.

The only exception would be if a designated, on-site meet physician is present and is able to examine the wrestler either immediately prior

to or immediately after the weigh-in. Covering a communicable condition shall not be considered acceptable and does not make the

wrestler eligible to participate.”

“ART. 4 . . . If a designated on-site meet physician is present, he/she may overrule the diagnosis of the appropriate health-care

professional signing the medical release form for a wrestler to participate or not participate with a particular skin condition.”

“ART. 5 . . . A contestant may have documentation from an appropriate health-care professional only indicating a specific condition such

as a birthmark or other non-communicable skin conditions such as psoriasis and eczema, and that documentation is valid for the duration

of the season. It is valid with the understanding that a chronic condition could become secondarily infected and may require re-

evaluation.”

Once a lesion is not considered contagious, it may be covered to allow participation.

Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling:

Bacterial Diseases (impetigo, boils): To be considered “non-contagious,” all lesions must be scabbed over with no oozing or discharge and no new lesions should

have occurred in the preceding 48 hours. Oral antibiotic for three days is considered a minimum to achieve that status. If new lesions continue to develop or drain

after 72 hours, CA-MRSA (Community Associated Methicillin Resistant Staphylococcus Aureus) should be considered and minimum oral antibiotics should be

extended to 10 days before returning the athlete to competition or until all lesions are scabbed over, whichever occurs last.