Michigan High School Athletic Association Medical History, Student And Parent Or Guardian Consent Form
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2MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.
MEDICAL HISTORY
• To be completed by parent or guardian or 18-year-old.
• Must be signed in three places by parent or guardian or 18-year-old.
A current year physical is one given on or after April 15 of the previous school year
STUDENT’S
LAST
FIRST
SEX
GRADE
DATE OF BIRTH
AGE
NAME
/
/
STUDENT’S
STREET
CITY
ZIP
ADDRESS
FATHER’S/GUARDIAN’S NAME
WORK PHONE
MOTHER’S / GUARDIAN’S NAME
WORK PHONE
FAMILY DOCTOR
OFFICE PHONE
HOME PHONE
INSURANCE STATEMENT & MEDICAL HISTORY
Our son / daughter will comply with the specific insurance regulations of the school district
Family Insurance Co.
Contract #
Signature of Parent or Guardian or 18-Year Old
HISTORY
YES
NO
HISTORY
YES
NO
HISTORY
YES
NO
Have you ever had:
Have you ever had:
Do you now have:
Fainting
Kidney Disease
Painful Joints
Diphtheria
Tuberculosis
Backaches
Scarlet Fever
Jaundice
Pounding of Heart
Rheumatism
Sickle-Cell Anemia
Shortness of Breath
Rupture
Frequent Urination
Rheumatic Fever
Cough
Poliomyelitis
Do you now have:
Nosebleeds
Blurred Vision
Pneumonia
Headaches
Frequent Sore Throats
Asthma
Fainting
Stomach Pains
Diabetes
Convulsions
Heart Disease
Blackouts
PHYSICAL EXAMINATION
To be completed by the examining MD, DO, Physician’s Assistant or Nurse Practitioner & returned directly to the patient. (Categories may be added or
deleted; check appropriate column.)
SYSTEM
NORMAL
ABNORMAL
SYSTEM
NORMAL
ABNORMAL
Urinalysis
Thyroid
Vision
Chest
Blood Pressure
Lungs
Pulse Rate
Heart
Ears
Abdomen
Nose
Hernia
Throat
Genitalia / Testicular Exam
Teeth - Cavities
Neurologic
Orthopedic
Muscular
RECOMMENDATIONS:
.
I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities not crossed out below
BASEBALL - BASKETBALL - BOWLING - COMPETITIVE CHEER - CROSS COUNTRY - FOOTBALL - GOLF -
GYMNASTICS - ICE HOCKEY - LACROSSE - SKIING - SOCCER - SOFTBALL - SWIMMING - TENNIS -TRACK - VOLLEYBALL - WRESTLING
SIGNATURE OF
CIRCLE ONE:
EXAMINER : X
MD
DO
PA
NP
PRINTED NAME
OF EXAMINER
MEDICAL TREATMENT CONSENT
To be completed by Parent or Guardian or 18-Year old
I, _________________________________________________, an 18-Year-old or the parent or guardian of
___________________________________________________, recognize that as a result of athletic participation, medical treatment on an emergency
basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do
hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then-existing circumstances and to
assume the expenses of such care.
SIGNATURE OF PARENT OR GUARDIAN OR 18-YEAR-OLD
DATE
x
FORM A (200M) 4/07
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