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2020-2021 STUDENT MEDICAL HISTORY FORM

Please complete the form below. Required fields marked *

STUDENT MEDICAL HISTORY FORM

Grade as of September 2020*
Answer Required

Please answer all the following questions.  For any "YES" answers, please explain at bottom of form.

Has a doctor ever denied or restricted your child's participation in sports for any reason?*
Answer Required
Does your son have any ongoing medical conditions?*
Answer Required
My son uses an Epi-Pen*
Answer Required
My son has active asthma, diagnosed by a physician*
Answer Required
My son uses an inhaler in school ( If yes, please complete the Self Administered Medication form)*
Answer Required
Has your son ever had significant surgery?*
Answer Required
Has your son ever passed out or nearly passed out during or after exercise?*
Answer Required
Has your son ever had discomfort, pain, tightness, or pressure in his chest during exercise?*
Answer Required
Does your son's heart ever race or skip beats during exercise?*
Answer Required
Has your son's doctor ever told him that he has any of the following?*
Answer Required
Does your son get light-headed, cough, or wheeze or feel more short of breath than expected during exercise?*
Answer Required
Has your son ever had an unexplained seizure?*
Answer Required
Has any family member or relative died of heart problems or an unexpected sudden death before the age of 50?*
Answer Required
Does your son have a history of cardiac arrhythmias? *
Answer Required
Does your son regularly use a brace or other assistive devices?*
Answer Required
Does your son have any rashes or other skin problems?*
Answer Required
Has your son ever had a head injury or concussion?*
Answer Required
Is your son on any special diet or does he need to avoid certain types of food?*
Answer Required