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HISTORY FORM PREPARTICIPATION PHYSICAL EVALUATION (Georgia Military College)

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■ PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Date of examination: _______________________________ Sport(s): _____________________________________________________
Sex assigned at birth (F, M, or intersex): _________________ How do you identify your gender? (F, M, or other): ___________________
GENERAL QUESTIONS
(Explain “Yes” answers at the end of this form.
Circle questions if you don’t know the answer.) Yes No
1. Do you have any concerns that you would like to
discuss with your provider?
2. Has a provider ever denied or restricted your
participation in sports for any reason?
3. Do you have any ongoing medical issues or
recent illness?
HEART HEALTH QUESTIONS ABOUT YOU Yes No
4. Have you ever passed out or nearly passed out
during or after exercise?
5. Have you ever had discomfort, pain, tightness,
or pressure in your chest during exercise?
6. Does your heart ever race, utter in your chest,
or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any
heart problems?
8. Has a doctor ever requested a test for your
heart? For example, electrocardiography (ECG)
or echocardiography.
HEART HEALTH QUESTIONS ABOUT YOU
(CONTINUED ) Yes No
9. Do you get light-headed or feel shorter of breath
than your friends during exercise?
10. Have you ever had a seizure?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
11. Has any family member or relative died of heart
problems or had an unexpected or unexplained
sudden death before age 35 years (including
drowning or unexplained car crash)?
12. Does anyone in your family have a genetic heart
problem such as hypertrophic cardiomyopathy
(HCM), Marfan syndrome, arrhythmogenic right
ventricular cardiomyopathy (ARVC), long QT
syndrome (LQTS), short QT syndrome (SQTS),
Brugada syndrome, or catecholaminergic poly-
morphic ventricular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or
an implanted debrillator before age 35?
List past and current medical conditions. _____________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (check box next to appropriate number)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
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BONE AND JOINT QUESTIONS Yes No
14. Have you ever had a stress fracture or an injury
to a bone, muscle, ligament, joint, or tendon that
caused you to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint
injury that bothers you?
MEDICAL QUESTIONS Yes No
16. Do you cough, wheeze, or have difculty
breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?
18. Do you have groin or testicle pain or a painful
bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or
rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus
(MRSA)?
20. Have you had a concussion or head injury that
caused confusion, a prolonged headache, or
memory problems?
21. Have you ever had numbness, had tingling, had
weakness in your arms or legs, or been unable
to move your arms or legs after being hit or
falling?
22. Have you ever become ill while exercising in the
heat?
23. Do you or does someone in your family have
sickle cell trait or disease?
24. Have you ever had or do you have any prob-
lems with your eyes or vision?
MEDICAL QUESTIONS (CONTINUED ) Yes No
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended
that you gain or lose weight?
27. Are you on a special diet or do you avoid
certain types of foods or food groups?
28. Have you ever had an eating disorder?
FEMALES ONLY Yes No
29. Have you ever had a menstrual period?
30. How old were you when you had your rst
menstrual period?
31. When was your most recent menstrual period?
32. How many periods have you had in the past 12
months?
Explain “Yes” answers here.
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete
and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: __________________________________________________________________________________________
Date: ________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
■ PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more-sensitive issues.
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
Date of birth: ____________________________
• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □ Y □ N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insufciency)
Eyes, ears, nose, and throat
• Pupils equal
• Hearing
Lymph nodes
Heart
a
• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs
Abdomen
Skin
• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or
tinea corporis
Neurological
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder and arm
Elbow and forearm
Wrist, hand, and ngers
Hip and thigh
Knee
Leg and ankle
Foot and toes
Functional
• Double-leg squat test, single-leg squat test, and box drop or step drop test
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination ndings, or a combi-
nation of those.
Name of health care professional (print or type): ___________________________________________________ Date: ___________________
Address: ________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
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■ PREPARTICIPATION PHYSICAL EVALUATION
MEDICAL ELIGIBILITY FORM
Name: _______________________________________________________ Date of birth: _________________________
□ Medically eligible for all sports without restriction
□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of
□ Medically eligible for certain sports
□ Not medically eligible pending further evaluation
□ Not medically eligible for any sports
Recommendations: ___________________________________________________________________________________
I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have
apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical
examination ndings are on record in my ofce and can be made available to the school at the request of the parents. If conditions
arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved
and the potential consequences are completely explained to the athlete (and parents or guardians).
Name of health care professional (print or type): __________________________________________ Date: ____________________________
Address: _________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
SHARED EMERGENCY INFORMATION
Allergies: ____________________________________________________________________________________________
Medications: ________________________________________________________________________________________
Other information: ____________________________________________________________________________________
Emergency contacts: ___________________________________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
Parental Consent For Athletic Participation
•
Although participation in supervised interscholastic athletics and activities may be one of the least hazardous in which students
will
WARNING:
engage, BY ITS NATURE, PARTICIPATION IN INTERSCHOLASTIC ATHLETICS INCLUDES A RISK OF INJURY WHICH MAY RANGE
IN SEVERITY FROM MINOR TO LONG TERM CATASTROPHIC, INCLUDING PERMANENT PARALYSIS FROM THE NECK DOWN OR
DEATH. Although serious injuries are not common in supervised school athletic programs, it is possible only to minimize,
not eliminate
the risk.
•
Participants can and have the responsibility to help reduce the chance of injury ry. PLAYERS MUST OBEY ALL SAFETY
RULES,
•
REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT
THEIR EQUIPMENT DAILY.
•
By signing this permission form, you acknowledge that you have read and understand this warning.
•
PARENTS OR STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN
THIS PERMISSION FORM.
(we) hereby give consent for to:
1.
Compete in athletics at Greene County High School of the Greene County School District in GHSA approved sports;
2.
To accompany any school team of which the student is a member on any of local or out of town trips;
3.
and I hereby verify that information included on this form is correct and understand that any false information may result in my son/daughter being
eclared ineligible.
he student is domiciled at the above address located in the Greene County High School District.
his student has attended Greene County High School for at LEAST one full year?
i
d
T
T
EMERGENCY CONTACTS
Parent Name:
Cell:
Parent Name:
Cell:
Emergency Contact:
Cell:
Athlete DOB: Current Grade:
INSURANCE INFORMATION
Please Initial
one
of the following statements regarding insurance cover age for our son/daughter for the 2021-22 school year
My Son/daughter is adequately and currently covered by accident insurance that will cover injuries sustained while
participating in interscholastic athletes (including but not limited to varsity and junior varsity football).
Insurance Company Name of Insured Policy Number
I wish to purchase the Benefit Plan provided for the Greene County School System. (www.studentinsurance-
kk.com). A signed copy of this Benefit Plan must be stapled to this form.
MEDICAL AUTHORIZATION
I certify that the medical history on this form is complete and accurate. I understand that this will serve as the basis for determining that my child,
may compete in high school athletics in Greene County Schools. I also understand that this medical
evaluation is only to determine fitness for athletics and is not to take the place of regular medical examinations. In case of an emergency or
accident on the school grounds or during any school activity involving my child, which in the opinion
of school authorities present requires immediate medical or surgical attention, I hereby grant permission to physicians, consulting physicians, athletic
trainers, emergency medical technicians, and other healthcare providers selected by school authorities to provide medical care and treatment (including
hospitalization if deemed appropriate by school authorities or an appropriate healthcare provider) unless I am present and request otherwise or
until I later
request otherwise.
THIS SIGNATURE CONSENTS TO ACKNOWLEDGEMENT OF DANGERS OF CONCUSSIONS, TRANSPORTATION LIABILITY, MEDIA
RELEASE, CODE OF CONDUCT, PERMISSION TO TREAT, ATHLETIC PARTICIPATION, VERIFICATION OF INSURANCE COVERAGE AND
MEDICAL AUTHORIZATION. THIS SIGNATURE ALSO REPRESENTS THAT ALL INFORMATION PROVIDED IN THIS ATHLETIC
PARTICIPATION FORM IS ACCURATE AND COMPLETE.
Parent Signature & Date
Date:
Athlete Signature
&
Date
Date:
Greene County Schools
1002 South Main Street Greensboro, GA 30642
Principal: James Peek (HS) Athletic Director: Mr. Eddie Hood
School
Greene County Schools is focused on developing a family friendly atmosphere. Therefore, we are asking all parents
of athletes to abide by our Parent/Spectator guidelines.
I agree:
1. I will refrain from coaching my child or other players during games and practices.
2. I will not speak poorly about the coaches with my child. Instead if I have a concern I will schedule a meeting
with the coach at a mutually agreed upon time. (Not on game day)
3. I understand that the expectation for all student-athletes is that they attend practice each day and arrive on
time unless they have received permission to do otherwise from their coaches.
4. I will respect the officials and their authority during games and will not jeer or mock officials.
5. I will remember that student athletes participate to have fun and that the game is for youth, not adults
6. I will teach my child that doing ones best is more important than winning, so that my child will never feel
defeated by the outcome of a game or his/her performance.
7. I will demand that my child treat other players, coaches, officials, and spectators with respect regardless of
race, creed, color, sex, or ability
8. I will promote the emotional and physical well being the student-athletes ahead of any personal desire I may
have for my child to win
9. I will not encourage any behaviors or practices that would endanger the health and well-being of the student
athletes.
10. I (and my guest) will be a positive role model for my child and encourage sportsmanship by showing respect
and courtesy, and by demonstrating positive support for all players', coaches, officials, and spectators at
every game, practice, or sporting event.
11. I (and my guest) will not engage in any kind of unsportsmanlike conduct with any official, coach, player, or
parent such as booing and taunting; refusing to shake hands, or using profane language or gestures.
12. I understand that any violation of this code of conduct will be cause for dismissal, suspension or permanent
expulsion from future athletic contests.
I have read, understand, and agree to the parents’ code of conduct at Greene County School System sporting events.
Parent Signature & Date
Date:
Parent Signature & Date
Date:
This form must be returned to the Athletic Office prior to athletic participation
Georgia High School Association
Student/Parent Concussion Awareness Form
SCHOOL:
DANGERS OF CONCUSSION
Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue.
Adolescent athletes are particularly vulnerable to the effects of concussion. Once considered little more than a minor “ding” to the
head, it is now understood that a concussion has the potential to result in death, or changes in brain function (either short-term or
long-term). A concussion is a brain injury that results in a temporary disruption of normal brain function. A concussion occurs when
the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head or body. Continued participation
in any sport following a concussion can lead to worsening concussion symptoms, as well as increased risk for further injury to the
brain, and even death.
Player and parental education in this area is crucial – that is the reason for this document. Refer to it regularly. This form must be
signed by a parent or guardian of each student who wishes to participate in GHSA athletics. One copy needs to be returned to the
school, and one retained at home.
COMMON SIGNS AND SYMPTOMS OF CONCUSSION
•
Headache, dizziness, poor balance, moves clumsily, reduced energy level/tiredness
•
Nausea or vomiting
•
Blurred vision, sensitivity to light and sounds
•
Fogginess of memory, difficulty concentrating, slowed thought processes, confused about surroundings or game
assignments
•
Unexplained changes in behavior and personality
•
Loss of consciousness (NOTE: This does not occur in all concussion episodes.)
BY-LAW 2.68: GHSA CONCUSSION POLICY: In accordance with Georgia law and national playing rules published by the National
Fe
deration of State High School Associations, any athlete who exhibits signs, symptoms, or behaviors consistent with a concussion
shall be immediately removed from the practice or contest and shall not return to play until an appropriate health care professional
has determined that no concussion has occurred. (NOTE: An appropriate health care professional may include licensed physician
(MD/DO) or another licensed individual under the supervision of a licensed physician, such as a nurse practitioner, physician assistant,
or certified athletic trainer who has received training in concussion evaluation and management.
a)
No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed, OR (b) cannot be
ruled out.
b)
Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professional prior to resuming
participation in any future practice or contest. The formulation of a gradual return to play protocol shall be a part of the medical
clearance.
By signing this concussion form, I give High School permission
to transfer this concussion form to the other sports that my child may play. I am aware of the dangers of concussion and
this signed concussion form will represent myself and my child during the _____________ school year. This form
will be stored with the athletic physical form and other accompanying forms required by the
School System.
I HAV
E READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT.
Student Name (P
rinted) Student Name (Signed) Date
Parent Name (P
rinted) Parent Name (Signed) Date
(Revised: 3/21)
Greene County
Georgia High School
Asso
c
iation
Student/Parent Sudden Cardiac Arrest Awareness
Fo
rm
SCHOOL:
1: Learn the Early Warning Signs
If you or your child has had one or more of these signs, see your primary care physician:
Fainting suddenly and without warning, especially during exercise or in response to loud sounds like doorbells, alarm
clocks or ringing phones
Unusual chest pain or shortness of breath during exercise
Family members who had sudden, unexplained and unexpected death before age 50
Family members who have been diagnosed with a condition that can cause sudden cardiac death, such as hypertrophic
cardiomyopathy (HCM) or Long QT syndrome
A seizure suddenly and without warning, especially during exercise or in response to loud sounds like doorbells, alarm
clocks or ringing phones
2: Learn to Recognize Sudden Cardiac Arrest
If you see someone collapse, assume he has experienced sudden cardiac arrest and respond quickly. This victim will be
unresponsive, gasping or not breathing normally, and may have some jerking (Seizure like activity). Send for help and start CPR.
You cannot hurt him.
3: Learn Hands-Only CPR
Effective CPR saves lives by circulating blood to the brain and other vital organs until rescue teams arrive. It is one of the most
important life skills you can learn – and it’s easier than ever.
Call 911 (or ask bystanders to call 911 and get an AED)
Push hard and fast in the center of the chest. Kneel at the victim’s side, place your hands on the lower half of the
breastbone, one on top of the other, elbows straight and locked. Push down 2 inches, then up 2 inches, at a rate of 100
times/minute, to the beat of the song “Stayin’ Alive.”
If an Automated External Defibrillator (AED) is available, open it and follow the voice prompts. It will lead you step-by-
step through the process, and will never shock a victim that does not need a shock.
By signing this sudden cardiac arrest form, I give High School
permission to transfer this sudden cardiac arrest form to the other sports that my child may play. I am aware of the
dangers of sudden cardiac arrest and this signed sudden cardiac arrest form will represent myself and my child during the
___________ school year. This form will be stored with the athletic physical form and other accompanying
forms required by the School System.
I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT.
Student Name (Printed) Student Name (Signed) Date
Parent Name (Printed) Parent Name (Signed) Date
(Revised: 3/21)
Greene County
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Completed 14 June 2022

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