WYOMING HIGH SCHOOL ACTIVITIES ASSOCIATION

SCHOOL PHYSICAL EXAMINATION

MEDICAL RECORD

PHYSICIANS STATEMENT MUST BE DATED AFTER JUNE 1 TO BE VALID FOR THE UPCOMING SCHOOL YEAR

Name Sex Age Date of Birth

Grade School Sport(s)

Address Phone

Personal Physician

In case of emergency, contact

Name Relationship Phone (H) (W)

Explain “Yes” answers below. Circle questions you

don’t know the answers to.
Yes No Yes No
1. Have you had a medical illness or injury since your last check 10. Do you use any special protective or corrective equipment or
up or sports physical? [] [] devices that aren’t usually used for your sport or position (for
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)? [] []
2. Have you ever been hospitalized overnight? [] [] 11. Have you had any problems with your eyes or vision? [] []
3. Are you currently taking any prescription of nonprescription Do you wear glasses, contacts, or protective eyewear? [] []
(over-the-counter) medications or pills or using an inhaler? [] []
4. Do you have any allergies (for example, to pollen, medicine, 12. Have you ever had a sprain, strain, or swelling after injury? [] []
food, or stinging insects)? [] []
5. Have you ever passed out during or after exercise? [] [] Have you broken or fractured any bones or dislocated any
joints? [] []
Have you ever been dizzy during or after exercise? [] [] Have you had any other problems with pain or swelling in
muscles, tendons, bones, or joints? [] []
If yes, check appropriate box and explain below
Have you ever had chest pain during or after exercise? [] [] Head Elbow Hip
Do you get tired more quickly than your friends do during Neck Forearm Thigh
exercise? [] [] Back Wrist Knee
Have you ever had racing of your heart or skipped heartbeats? [] [] Chest Hand Shin/calf
Have you had high blood pressure or high cholesterol? [] [] Shoulder Finger Ankle
Have you ever been told you have a heart murmur? [] [] Upper Arm Foot
Has any family member or relative died of heart problems or 13. Do you want to weigh more or less than you do now? [] []
of sudden death before age 50? [] []
Have you had a severe viral infection (for example, Do you lose weight regularly to meet weight requirements
myocarditis or mononucleosis) within the last month? [] [] for your sport? [] []
Has a physician ever denied or restricted your participation in 14. Do you feel stressed out? [] []
sports for any heart problems? [] []
6. Do you have any current skin problems (for example, itching, 15. Record the dates of your most recent immunizations (shots)
rashes, acne, warts, fungus, or blisters)? [] [] for:
7. Have you ever had a head injury or concussion? [] [] Tetanus Measles `
Have you ever been knocked out, become unconscious, or lost Hepatitis B Chickenpox `
your memory? [] [] FEMALES ONLY
Have you ever had a seizure? [] [] 16. When was your first menstrual period? `
Do you have frequent or severe headaches? [] [] When was your most recent menstrual period? `
Have you ever had numbness or tingling in your arms, hands, How much time do you usually have from the start of one period
legs, or feet? [] [] to the start of another? `
Have you ever had a stinger, burner, or pinched nerve? [] [] How many periods have you had in the last year? `
8. Have you ever become ill from exercising in the heat? [] [] What was the longest time between periods in the last year?
9. Do you cough, wheeze, or have trouble breathing during or Explain “Yes” answers here: `
after activity? [] [] `
Do you have asthma? [] [] `
Do you have seasonal allergies that require medical `
treatment? [] [] `
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete Signature of parent/guardian Date `

PARENT/GUARDIAN CONSENT FOR EMERGENCY MEDICAL ASSISTANCE

I hereby authorize School District and its faculty members in charge of my child named below to obtain all
necessary medical care for my child in the event that I cannot be reached to authorize it myself. I hereby authorize any licensed physician and/or medical personnel
to render necessary medical treatment to my child.

Student’s Name Work Phone Number; Father

Address Mother
Home Phone Number

INSURANCE INFORMATION: Company Policy #

Insured Person
Policy Holder’s Social Security Number

Signature acknowledges that we have read and understand the above warning and we give consent for emergency assistance that might be needed.

Date Signature of Parent/Guardian

8/01 {over} A7

WYOMING HIGH SCHOOL ACTIVITIES ASSOCIATION

 SCHOOL PHYSICAL EXAMINATION
MEDICAL RECORD

PHYSICIANS STATEMENT MUST BE DATED AFTER JUNE 1 TO BE VALID FOR THE UPCOMING SCHOOL YEAR

DATE OF EXAM

Name Date of Birth `

Height Weight % Body fat (optional) Pulse BP / ( / , / )

Vision R 20/ L 20/ Corrected: Y N Pupils: Equal Unequal `

*NORMAL* ABNORMAL FINDINGS

MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand
Hip/thigh
Knee
Leg/ankle
Foot
*Normal indicated by check or N

Cleared

* Cleared after completing evaluation/rehabilitation for: __________________________________________________________________

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

* Not cleared for: Reason:

Recommendations:

*IF THESE BOXES ARE CHECKED, A COPY OF THIS FORM NEEDS TO BE SENT TO THE APPROPRIATE SCHOOL
DISTRICT.

Name of physician (print/type) Date

Address Phone

Signature of physician , MD or DO

STUDENT/PARENT/GUARDIAN INFORMED CONSENT

Participation in all activities requires the acceptance of risk of possible serious injury. The risk can be minimized by following your
coaches’ rules and procedures, by familiarizing yourself with the rules of the activity, and by following the specific rules issued by manufacturers
for the safe use of your activity equipment. The risk is always there, but you can help minimize it by making safety a shared responsibility.
When you make the decision to participate in an activity, you are assuming the shared responsibility of following the activities rules, the coaches’
rules, and the equipment manufacturer’s rules. You, as a participant, can help make the activity safer by not intentionally using techniques which
are illegal and which can cause serious injury.

Your signature below indicates that you have been informed about the importance of following rules in activities participation; and you
realize that there is a risk of being injured that is inherent in all activities. You realize that the risk of injury may be severe, including the risk of
fractures, brain injuries, paralysis or even death.

Activity programs specifically excluded:

Date Signature of Student

Signature of Parent