Physician'S Health Appraisal Form Page 2
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1
2HEALTH HISTORY
Parent Section
CHAPPAQUA CENTRAL SCHOOL DISTRICT
Name: __________________________________________________________
Date: ___________________________
Address: ________________________________________________________
Grade entering
___________
(as of Sept.)
Home Phone: ____________________ Cell / Contact Phone: (______) ________________ Date of Birth: ________________
HGHS
Seven Bridges
Robert E. Bell
School Attending:
List the specific sports in which your child will be participating for each season:
Fall: ______________________________ Winter: _____________________________ Spring: __________________________
Required Past Medical History
(to be completed by parent / guardian)
Yes
No
Dates / Details
Hospitalizations
Operations / Surgery
Daily Medications
Allergies
Significant Illnesses
and/or Injuries
Current conditions being
monitored by a physician
Required for Sports Participation
- Additional History
(to be completed by parent / guardian)
Yes
No
Dates / Details
Ever denied full
athletic participation?
Absence of a paired organ
Anemia
Asthma / respiratory disorder
Concussion (Number ____)
Frequent or Severe Headaches
Fainting / passing out
Heat exhaustion / heat stroke
Heart disease - student
Heart disease - family
Hypertension
Mononucleosis
Seizures / epilepsy
Describe any major musculo-skeletal
injury or problem that occurred in the
last 3 years
Parent / Guardian Attestation
(For All Sports Participation)
I declare that the above information is an accurate and true reflection of my child’s condition.
Parent /Guardian Signature: ___________________________________________________ Date: ______________________
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Parent category: Medical