Get Sports Form 2003-2024

If you do not want the physician to make an entry for the Maturation Index write No The term clinician appears on the Sports Examination form and refers to physicians nurse-practitioners and physicians assistant. The physical examination may be performed by any of these medical personnel. As the Sports Examination form indicates the student s medical record is strictly confidential and is on file in the school medical office. The index is one indicator of a child s bone development and is helpful to the physician in assessing the total development of the child and his or her fitness for sports participation. However as inclusion of the Maturation Index is optional the parent/guardian decides whether or not the physician includes the rating. If you do not want the physician to make an entry for the Maturation Index write No The term clinician appears on the Sports Examination form and refers to physicians nurse-practitioners and physicians assistant. The physical examination may be performed by any of these medical personnel. As the Sports Examination form indicates the student s medical record is strictly confidential and is on file in the school medical office. The student s medical record is not part of his or her academic record and is not subject to examination by anyone except authorized personnel. PLEASE NOTE ALL STUDENTS SHOULD RECEIVE REGULARLY SCHEDULED COMPLETE PHYSICAL EXAMINATION BY A PHYSICIAN OF THE PARENT/GUARDIAN S CHOICE. Parentnotice misc 02 25-1190. The physical examination and the Department of Health/Department of Education Sport Examination form may be completed by the Department of Health physician at no cost to you or by your personal physician. The attached Sports Examination form is more comprehensive than the form it replaced. The purpose of this new form is to ensure that your child receives a The American Academy of Pediatrics the New York City Department of Health and the Department of Education strongly recommend that every student have a development and should be included for the protection of the student. Assessment Plan GUIDELINES FOR DISQUALIFYING CONDITIONS FOR SPORTS PARTICIPATION CONDITIONS NONCONTACT ENDURANCE Acute infections Respiratory genitourinary infectious mononucleosis hepatitis active rheumatic fever active tuberculosis boils furuncles impetigo X Obvious physical immaturity in comparison with other competitors Obvious growth retardation Hemorrhagic disease Hemophilia purpura and other bleeding tendencies Diabetes inadequately controlled Jaundice whatever cause EYES Absence or loss of function of one eye Sever myopia even if correctable EARS Significant impairment RESPIRATORY Tuberculosis active or under treatment Severe pulmonary insufficiency CARDIOVASCULAR Rheumatic heart disease coaretation or aorta cyanotic heart disease recent carditis or any etiology Hypertension on organic basis Significant residual heart disease following heart surgery for congenital or acquired heart disease LIVER enlarged SPLEEN enlarged HERNIA inguinal or femoral MUSCULOSKELETAL Symptomatic inflammation Functional inadequacy incompatible with the contact or skill demand of the sport NEUROLOGICAL History of symptoms of previous serious head trauma or repeated concussions Convulsive disorder not completely controlled by medication Previous surgery on head or spine RENAL Absence of one kidney Renal disease GENITALIA Absence of one testicle Undescended testicle The Guidelines for Disqualifying Conditions for Sports Participation listed on this form serve only as recommendations to the examining physician. The decision as to whether a student is qualified to participate should be individualized. In case of differences of interpretation the decision of the school physician has precedence. Appeals may be requested through established procedures. IMPORTANT NOTICE TO PARENTS / GUARDIANS New York State Commissioner of Education Regulations requires every student to have a physical examination before participating in senior high school interscholastic sport activities. DEPARTMENT OF HEALTH THE CITY OF NEW YORK BOARD OF EDUCATION INTERSCHOLASTIC SPORTS EXAMINATION - CONFIDENTIAL PART 1 to be filed in Student s Health folder Regulation of the Chancellor OSIS I. D. NAME ADDRESS TELEPHONE SPORT SCHOOL BOROUGH HOMEROOM GRADE DATE OF BIRTH EMERGENCY TELEPHONE PARENTAL PERMISSION I have reviewed the STUDENT MEDICAL HISTORY section below and I agree with the answers. I give permission for to have a physical examination. I understand that completion of the Maturation Index is optional. SIGNATURE RELATIONSHIP CLINICIAN S RECOMMENDATIONS Based on my review of the history and physical examination as noted below and on the back of this form and review of the guidelines for this student 1 May participate in the following sports DRAW A LINE TRHOUGH ANY SPORTS TO BE OMITTED CONTACT Football Baseball Soccer Hockey Wrestling Lacrosse Softball Cricket Rugby ENDURANCE Gymnastics Swimming Track Field Cross-country Tennis Volleyball Handball Fencing Double Dutch OTHER Bowling Golf Crew Cheerleading Field Events Archery DATE OF LAST TETANUS BOOSTER 2 Special conditions for participation e.g. pre-exercise medication or protective equipment if any CLINICIAN REGISTRY ADDRESS STUDENT S MEDICAL HISTORY Clinician s Comments To be filled out by student and parent Has anyone in your family under age 45 died suddenly Have you ever had Concussion or been knocked out Fainting Heat Stroke Epilepsy seizures or fits Head or neck injury Very bad vision in one or both eyes Yes No Do you wear glasses contacts other Hearing loss or deafness Perforated ear drum or tubes in ears Draining ears PART 1 STUDENT S HEALTH FOLDER CONTINUED Sinus problems or hay fever Braces or removable teeth Any broken bones Dislocation or other serious problems Serious foot problem Back injury or frequent backaches Ankle or knee injury or problem Other joint problems Do you have a hernia Boys Any problems with testicles Girls Any menstrual problem Age at first menstrual period Do you miss school because of your period Diabetes Single illness for more than 10 days Any operations Easy bruising or bleeding tendency Anemia Asthma Bee sting allergy Other allergies food or medicine Heart trouble or murmurs High blood pressure Cough lasting more than 3 weeks Chest pain or faintness with exercise Kidney problems Skin infections Do you take any medicines Do you smoke Have you ever been told not to play any sport because of your health PHYSICAL EXAMINATION A complete physical examination for all students is recommended. Omission of the Maturation Index will not disqualify a student from participation. Height Vision Uncorrected L20/ Skin Eyes ENT Mouth Teeth Neck Cardiovascular Lungs Chest Spine Abdomen Genitalia Hernia Pulse Blood Pressure Corrected Normal Abnormal Comments Maturation Index Extremities Orthopedic Neuromuscular Other tests if done Lab ECC ect. D. NAME ADDRESS TELEPHONE SPORT SCHOOL BOROUGH HOMEROOM GRADE DATE OF BIRTH EMERGENCY TELEPHONE PARENTAL PERMISSION I have reviewed the STUDENT MEDICAL HISTORY section below and I agree with the answers. I give permission for to have a physical examination. I understand that completion of the Maturation Index is optional. SIGNATURE RELATIONSHIP CLINICIAN S RECOMMENDATIONS Based on my review of the history and physical examination as noted below and on the back of this form and review of the guidelines for this student 1 May participate in the following sports DRAW A LINE TRHOUGH ANY SPORTS TO BE OMITTED CONTACT Football Baseball Soccer Hockey Wrestling Lacrosse Softball Cricket Rugby ENDURANCE Gymnastics Swimming Track Field Cross-country Tennis Volleyball Handball Fencing Double Dutch OTHER Bowling Golf Crew Cheerleading Field Events Archery DATE OF LAST TETANUS BOOSTER 2 Special conditions for participation e.g. pre-exercise medication or protective equipment if any CLINICIAN REGISTRY ADDRESS STUDENT S MEDICAL HISTORY Clinician s Comments To be filled out by student and parent Has anyone in your family under age 45 died suddenly Have you ever had Concussion or been knocked out Fainting Heat Stroke Epilepsy seizures or fits Head or neck injury Very bad vision in one or both eyes Yes No Do you wear glasses contacts other Hearing loss or deafness Perforated ear drum or tubes in ears Draining ears PART 1 STUDENT S HEALTH FOLDER CONTINUED Sinus problems or hay fever Braces or removable teeth Any broken bones Dislocation or other serious problems Serious foot problem Back injury or frequent backaches Ankle or knee injury or problem Other joint problems Do you have a hernia Boys Any problems with testicles Girls Any menstrual problem Age at first menstrual period Do you miss school because of your period Diabetes Single illness for more than 10 days Any operations Easy bruising or bleeding tendency Anemia Asthma Bee sting allergy Other allergies food or medicine Heart trouble or murmurs High blood pressure Cough lasting more than 3 weeks Chest pain or faintness with exercise Kidney problems Skin infections Do you take any medicines Do you smoke Have you ever been told not to play any sport because of your health PHYSICAL EXAMINATION A complete physical examination for all students is recommended. Omission of the Maturation Index will not disqualify a student from participation. Height Vision Uncorrected L20/ Skin Eyes ENT Mouth Teeth Neck Cardiovascular Lungs Chest Spine Abdomen Genitalia Hernia Pulse Blood Pressure Corrected Normal Abnormal Comments Maturation Index Extremities Orthopedic Neuromuscular Other tests if done Lab ECC ect. Assessment Plan GUIDELINES FOR DISQUALIFYING CONDITIONS FOR SPORTS PARTICIPATION CONDITIONS NONCONTACT ENDURANCE Acute infections Respiratory genitourinary infectious mononucleosis hepatitis active rheumatic fever active tuberculosis boils furuncles impetigo X Obvious physical immaturity in comparison with other competitors Obvious growth retardation Hemorrhagic disease Hemophilia purpura and other bleeding tendencies Diabetes inadequately controlled Jaundice whatever cause EYES Absence or loss of function of one eye Sever myopia even if correctable EARS Significant impairment RESPIRATORY Tuberculosis active or under treatment Severe pulmonary insufficiency CARDIOVASCULAR Rheumatic heart disease coaretation or aorta cyanotic heart disease recent carditis or any etiology Hypertension on organic basis Significant residual heart disease following heart surgery for congenital or acquired heart disease LIVER enlarged SPLEEN enlarged HERNIA inguinal or femoral MUSCULOSKELETAL Symptomatic inflammation Functional inadequacy incompatible with the contact or skill demand of the sport NEUROLOGICAL History of symptoms of previous serious head trauma or repeated concussions Convulsive disorder not completely controlled by medication Previous surgery on head or spine RENAL Absence of one kidney Renal disease GENITALIA Absence of one testicle Undescended testicle The Guidelines for Disqualifying Conditions for Sports Participation listed on this form serve only as recommendations to the examining physician. The decision as to whether a student is qualified to participate should be individualized. In case of differences of interpretation the decision of the school physician has precedence. .