Michigan High School Athletic Association Medical History, Physical Exam & Clearance & Consent Forms
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1
2MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.
MEDICAL HISTORY
• To be completed by parent or guardian or 18-year-old.
• Must be signed below 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
LAST
FIRST
MI
SEX
GRADE
DATE OF BIRTH
AGE
STUDENT’S NAME:
---
---
NUMBER AND STREET
CITY
ZIP
STUDENT’S ADDRESS:
NAME OF FATHER OR GUARDIAN
WORK PHONE
NAME OF MOTHER OR GUARDIAN
WORK PHONE
FAMILY DOCTOR
OFFICE PHONE
STUDENT’S HOME PHONE
INSURANCE STATEMENT AND MEDICAL HISTORY
Our Son/Daughter will comply with the specific insurance regulations of the school district and the Medical History questions are as complete and correct as possible.
Family Insurance Co: ______________________________________________________________________ Contract #: _______________________________________
Signatures of Student: ___________________________________ & Parent/Guardian or 18 Year Old: ___________________________________________
GENERAL QUESTIONS
YES
NO
YOUR FAMILY’S HEART HEALTH QUESTIONS
YES
NO
MEDICAL QUESTIONS
YES
NO
Has a Doctor ever denied or restricted your participation in
Does anyone in your family have arrhythmogenic
Do you have any concerns that you would like to
Sports for any reason?
right ventricular cardiomyopathy, long QT syndrome?
discuss with a doctor?
Has any family member or relative died of heart
Do you have any ongoing medical conditions? If so, please
Were you born without or are you missing an organ?
Problems or had an unexpected or unexplained sudden
Identify by Circling: Asthma
Anemia
Diabetes
Identify by circling: A kidney An eye Your spleen
death before age 50 (including drowning, unexplained
Infections Other: ________________
A testicle (males)
Any other organ? _____________
car accident or sudden infant death syndrome) ?
Have you ever spent the night in the hospital?
Does anyone in your family have catecholaminergic
Have you ever had an eating disorder?
polymorphic ventricular tachycardia, short QT syndrome?
Have you ever had surgery?
Do you worry about your weight?
HEART HEALTH QUESTIONS ABOUT YOU
YES
NO
BONE AND JOINT QUESTIONS
YES
NO
Have you ever had a head injury or concussion?
Have you ever passed out or nearly passed out DURING
Have you ever had an injury to a bone, muscle, ligament
Have you ever had a hit or blow to the head that caused
or after exercise?
or tendon that caused you to miss a practice or a game?
confusion, prolonged headache, or memory problems?
Have you ever had discomfort, pain, tightness or pressure
Have you ever had any broken or fractured bones or
Have you ever had numbness, tingling, or weakness in
in your chest during exercise?
dislocated joints?
your arms or legs after being hit or falling?
Do you get lightheaded or feel more short of breath than
Have you ever had an injury that required x-rays, MRI,
Have you ever been unable to move your arms or legs
expected during exercise?
CT scan, injections, therapy, a brace or cast or crutches?
after being hit or falling?
Do you get more tired or short of breath more quickly than
Have you ever been told that you have neck instability or
Are you trying to or has anyone recommended that you
your friends during exercise?
atlantoaxial instability (Down syndrome or dwarfism)?
gain or lose weight?
Has a doctor ever ordered a test for your heart?
Have you ever had an x-ray for neck instability or
Are you on a special diet or do you avoid certain
For example: ECG/EKG, echocardiogram
atlantoaxial instability (Down syndrome or dwarfism)?
types of foods?
Have you ever had an unexplained seizure or do you have
Do you regularly use a brace, orthotics, or other assistive
Do you wear protective eyewear, such as goggles, or a
a history of seizure disorder?
device?
face shield?
Does your heart ever race or skip beats (irregular beat)
Do any of your joints become painful, swollen, feel warm
Do you or someone in your family have sickle cell trait
during exercise?
or look red?
or disease?
Has a doctor ever told you that you have high blood
Do you have any history of juvenile arthritis or
Have you had any problems with your eyes or vision
pressure?
connective tissue disease?
or had any eye injuries?
Has a doctor ever told you that you have high cholesterol?
Have you ever had a stress fracture?
Do you wear glasses or contact lenses?
Has a doctor ever told you that you have Kawasaki disease?
Have you a bone, muscle, or joint injury bothering you?
Have you ever had herpes or MRSA skin infection?
Has a doctor ever told you that you have other heart
Have you had infectious mononucleosis (mono) within
IMMUNIZATION HISTORY
YES
NO
problems?
the last month?
Has a doctor ever told you that you have a heart infection?
Are you missing any recommended vaccines (Tdap, Flu,
Do you have any rashes, pressure sores, or other skin
MCV4, HPV, Varicella, MMR)
problems?
Has a doctor ever told you that you have a heart murmur?
MEDICAL QUESTIONS
YES
NO
Do You Have Any Allergies?
YOUR FAMILY’S HEART HEALTH QUESTIONS
YES
NO
Have you ever become ill while exercising in the heat?
FEMALES ONLY
YES
NO
Does anyone in your family have a heart problem,
Do you cough, wheeze, or have difficulty breathing
Have you ever had a menstrual period?
Pacemaker, or implanted defibrillator?
during or after exercise?
Does anyone in your family have hypertrophic
Do you have headaches or get frequent muscle cramps
How old were you when you had your first
cardiomyopathy, Marfan syndrome, Brugada syndrome?
When exercising?
menstrual period?
Anyone in your family had unexplained fainting?
Do you have pain, a painful bulge or hernia in the groin?
How many periods have you had in the last
Anyone in your family had unexplained seizures?
Is there any one in your family who has asthma?
twelve (12) months?
Anyone in your family had unexplained near drowning?
Have you ever used an inhaler or taken asthma medicine?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature: ____________________________________ Signature of: ________________________________ Date: ________
Of Student
Parent/Guardian
------------------------------- < DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > ------------------------------------
EMERGENCY INFORMATION – To Be Completed by Parent or Guardian or 18 Year Old
Student’s Name: ____________________________________________________________________________ Grade: _______
IN EMERGENCY
1) _________________________________ Phone #: ___________________ Cell #: ____________________
CONTACT or 2) _______________________________ Phone #: ___________________ Cell #: ____________________
Family Doctor: ______________________________________________________________ Phone: ______________________
Allergies: _____________________________________________________________________________________
Drug Reactions: _____________________________________________________________________________________
Current Medications: _____________________________________________________________________________________
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