NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

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1 NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: Sex: This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your child s regular physician where important preventive health information can be covered. Athlete s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your knowledge. Parent s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or don t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk during sports activity. Physician s Directions: We recommend carefully reviewing these questions and clarifying any positive or Don t Know answers. Explain Yes answers below Yes No Don t know 1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, etc.]? q q q List: 2. Is the athlete presently taking any medications or pills? q q q 3. Does the athlete have any allergies (medicine, bees or other stinging insects, latex)? q q q 4. Does the athlete have the sickle cell trait? q q q 5. Has the athlete ever had a head injury, been knocked out, or had a concussion? q q q 6. Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities? q q q 7. Has the athlete ever passed out or nearly passed out DURING exercise, emotion or startle? q q q 8. Has the athlete ever fainted or passed out AFTER exercise? q q q 9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)? q q q 10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise? q q q 11. Has the athlete ever been diagnosed with exercise-induced asthma? q q q 12. Has a doctor ever told the athlete that they have high blood pressure? q q q 13. Has a doctor ever told the athlete that they have a heart infection? q q q 14. Has a doctor ever ordered an EKG or other test for the athlete s heart, or has the athlete ever been told they have a q q q murmur? 15. Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of their q q q heart racing or skipping beats? 16. Has the athlete ever had a seizure or been diagnosed with an unexplained seizure problem? q q q 17. Has the athlete ever had a stinger, burner or pinched nerve? q q q 18. Has the athlete ever had any problems with their eyes or vision? q q q 19. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of any bones or joints? q q q q Head q Shoulder q Thigh q Neck q Elbow q Knee q Chest q Hip q Forearm q Shin/calf q Back q Wrist q Ankle q Hand q Foot 20. Has the athlete ever had an eating disorder, or do you have any concerns about your eating habits or weight? q q q 21. Has the athlete ever been hospitalized or had surgery? q q q 22. Has the athlete had/been: 1. Little interest or pleasure in doing things; 2. Feeling down, depressed, or hopeless q q q for more than 2 weeks in a row; 3. Feeling bad about himself/herself that they are a failure, or let their family down; 4. Thoughts that he/she would be better off dead or hurting themselves? 23. Has the athlete had a medical problem or injury since their last evaluation? q q q FAMILY HISTORY q q q 24. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death q q q syndrome [SIDS], car accident, drowning)? 25. Has any family member had unexplained heart attacks, fainting or seizures? q q q 26. Does the athlete have a father, mother or brother with sickle cell disease? q q q Elaborate on any positive (yes) answers: If additional space is needed attach a separate sheet By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is correct to the best of my knowledge. Furthermore, as parent or legal custodian, I give consent for this examination and give permission for my child to participate in sports. Signature of parent/legal custodian: Date: Signature of Athlete: Date: Phone #:

2 Athlete s Name Age Date of Birth Height Weight BP ( % ile) / ( % ile) Pulse Vision R 20/ L 20/ Corrected: Y N Physical Examination (Below Must be Completed by Licensed Physician, Nurse Practitioner or Physician Assistant) PULSES HEART LUNGS SKIN NECK/BACK SHOULDER KNEE ANKLE/FOOT Other Orthopedic Problems HEENT ABDOMINAL GENITALIA (MALES) HERNIA (MALES) These are required elements for all examinations NORMAL ABNORMAL ABNORMAL FINDINGS Optional Examination Elements Should be done if history indicates Clearance: q A. Cleared q B. Cleared after completing evaluation/rehabilitation for : q *** C. Medical Waiver Form must be attached (for the condition of: ) q D. Not cleared for: q Collision q Contact Due to: q Non-contact Strenuous Moderately strenuous Non-strenuous Additional Recommendations/Rehab Instructions: Name of Physician/Extender: Signature of Physician/Extender MD DO PA NP (Signature and circle of designated degree required) Date of exam: Physician Office Stamp: Address: Phone (*** The following are considered disqualifying until appropriate medical and parental releases are obtained: post-operative clearance, acute infections, obvious growth retardation, uncontrolled diabetes, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or Stage 2 hypertension, enlarged liver or spleen, a chronic musculoskeletal condition that limits ability for safe exercise/sport (i.e. Klippel-Feil anomaly, Sprengel s deformity), history of uncontrolled seizures, absence of/ or one kidney, eye, testicle or ovary, etc.) This form is approved by the North Carolina High School Athletic Association Sports Medicine Advisory Committee and the NCHSAA Board of Directors. This form is current as of April 2016

3 Cardiac Screening in High School Athletes Sudden cardiac arrest in high school athletes is fairly uncommon, however, cardiac abnormalities are the most common cause of sudden death during high school sporting events. During a sports history and physical, a physician can determine if a student athlete could be at risk for a cardiovascular abnormality. Family history, routine physical examination, and checking the athlete s blood pressure can aid in determining if the student is at risk. The physician could then suggest further screening for cardiovascular abnormalities as deemed necessary. Screening Echocardiography An echocardiogram is a simple test using ultrasound that can be done within minutes to rule out abnormalities in the heart. A cardiac sonographer places ultrasound gel on the patient s chest, and using an ultrasound probe and machine, acquires multiple still and motion images for a cardiologist to review. The exam is safe and painless, and no radiation is emitted from the equipment. After the cardiologist has reviewed the images, any potential abnormalities are reported and whether any further testing and follow up is needed. I hereby consent to a screening echocardiogram if recommended during the sports physical examination. I release Rex Healthcare and any of its employees of any liability arising from, connected to, or associated with the administration of the screening echocardiogram. I understand that this echocardiogram will simply screen for 3 of the most common causes of sudden cardiac death in athletes potentially seen by chest wall echocardiography. Furthermore, I understand that the acquired images will be reviewed by a cardiologist who will contact me if further follow-up is recommended. I also understand that the responsibility for initiating a follow-up examination to confirm the results of this test, and for obtaining professional medical assistance, is mine alone. Patient Signature (or authorized representative if patient is a minor) Relationship, if not patient: Date Rex Healthcare is proud to support the health needs of our local community. For more information on our services, visit rexhealth.com

4 Sport Pre-participation History Form This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your child s regular physician where important preventive health information can be covered. I have answered and reviewed the questions in the physical form and promise that all are accurate responses. Moreover, I give permission for the athlete to participate in sports. By signing below, I recognize that (i) this sports participation screening is simply a general examination, required by your county athletic association and it cannot be expected to discover or uncover all possible (even life-threatening) abnormalities; and (ii) if the athlete or someone in his/her family has a history of heart problems or sudden death or disease, then the health care providers involved in this screening recommend that the athlete be seen prior to the athlete s participation in sports by the athlete s primary care doctor (family doctor or pediatrician) and/or cardiologist (heart doctor) or any other doctor suggested by the primary care doctor and/or cardiologist. Sickle cell trait Sickle cell trait is an inherited blood condition that is benign and does not have any symptoms, except in cases of extreme heat. However, the presence of this trait can help identify those people who may have, or be carriers for, a more severe condition called sickle cell disease, or sickle cell anemia. Sickle cell anemia can be potentially deadly and is a significant risk to sport participation. The medical history and screening form asks if you have tested positive for sickle cell trait. This is determined by a simple blood test, usually done at birth. If you do not know the results of this test, you may want to check with your child s pediatrician. Signature of Athlete s Parent/Legal Custodian Date Signature of Athlete: Date Phone number

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