LHSAA MEDICAL HISTORY EVALUATION IMPORTANT: This form must be completed annually, kept on file withthe school, & is subject to inspection by the Rules Compliance Team. Name Schoo! Grade: Date: Sports Sex: M/F Date of Binh ‘Age.__Cell Phone. Home Address: City State,___Zip Code: Home Phone! Parent / Guardian: Employer Work Phone: = FAMILY MEDICAL HISTORY: Has any member of your famly under age 50 had these condiions? ‘Yes No Condition Whom Yes No Condition ‘Whom Yes No Condition Whom 1D DHean attackDisease 2D Sudden Death OG Adhats 0D astoke = DG High Blood Pressure G- Kicney Disease 1D Diabetes = BG Sie Cel TrawAnemia BG Epilepsy ATHLETE'S ORTHOPAEDIC HISTORY: — Has the athlete had any of the folowing injuries? ‘Yes No Condition Date ‘Yes No Condition Date Yes No Condition Dato DG Heed Injury! Concussion DO Neck injury Stinger DO ShoulderL/R. Oo EltowL/R DG Arm/Wrist/ Hand 7 DG Back 00 Hue DG Thigh L/R DG kneel OG Lower legis Rk DD Chronic Shin spints OO Anke L/R BG FooliR GG Severe Muscle Strain 1G Pinched Newe OO Chest Previous Surgeries: ATHLETE, r Has the atilete ad any of these conditions?” ‘Yes No Condition Yes No Condition Yes No Condition OO Heart Murmur Chest Pain/Tightness «Asthma / Prescribed Inhaler GG Menstrual kregularties: Last Cyt: OG Seizures DG Shortness of breath/ Coughing Rapid weightloss / gain CD Kidney Oisease DG Hema DD Take supplomentsitamins DG Ireguiar Heartbeat DG Knocked out / Concussion DG Heat related problems OD Single Testicle OG Hear Disease DG Recent Monanucieos| 1G High Btood Pressure BG Diabetes DG Enarged Spleen DO Dizzy Fainting DD Liver Disease DD Sickle Col TraivAnemia DG Organ Loss (kicney spleen et) DG Tuberculosis DD Overnight in hospital 5D Surgery BD Prescribed EPI PEN DG Alieries (Food, Drugs), DG Medications List Dates for: Last Tetanus Shot. ‘Measles immunization: ‘Meningie Vaccine? "ARENTS WAIVER Fi To the best of our knowledge, we have given true & accurate information & hereby grant permission forthe physical scraning evaluation, We understand the evaluation involves a limited examination and the screening is not intended to ror wil it prevent injury or sudden death. We further understand that the ‘examination is provided vthout expectaton of payment, there shall be no cause of action pursuant to Lousiana R.S.9:2798 agains the team volunteer heelth- ‘are provider andlor employer under Louisiana law. ‘This waiver, executed on the date below by he undersigned metical doctor, osteopathic doctor, rurse practioner or physician's assistant and parent ofthe ‘student athlete named above, is done so in compliance with Lousiana law withthe fll understanding thal ther shall be no cause of action for any loss or damage ‘caused by any act or omission related io the health care services if rendered voluntary and wilhout expectation of payment herein unis such los or damage was caused by gross negligence. Addlionally 1. thin the judgment of a schoo! representative, the named student-athlete needs care or veatment as a resul ofan injury ‘or sickness, ! do hereby request, consent and authorize fo such care as may be deemed necessary Yes No 2. understand that ifthe mecical status of my child changes in any significant manner after hisiher physical examination, {will notly his er principal of the change immediatly. : Yes No 3. give my permission forthe athletic trainer to release Information concerning my child's injures to the head coachithicic rocterprincpal of hither sch. . ie he 4. By my signature below, | am agreeing to alow ry chie's mecicalhistorylexam form and al eigibiilyTorms to be raviowed by the LHSAA or its Representatives... : Yes No Data Signed by Parent Signature of Parent ‘Typed or Printed Name of Parent I, COMPLETED ANNUALLY BY MEDICAL DOCTOR (MD), OSTEOPATHIC DR. (00), NURSE PRACTITIONER (APRN) or PHYSICIAN'S ASSISTANT (PA) m7 von Gos ranore Po ‘GENERAL MEDICAL EXAM : THOPAEDI -— ee er ie corset 1 Sete ce Lungs: a a Carvical o a hae | seek 5 oa nen 2 —. oe 8 8 = qT Nera T ASN SSE Eu Bent Po a 38 = | Foy con of ac ee 8 8 WS egos 1 User ecieony From ths ted srening sa no reason whys sunt anne purtepte i atnicn, ~. g 38 {yatucon a senne bird a 68 {Cleared after further evaluation and treatment for:__ [Not cleared for: contact _non-contact, Printed Name of WD, DO, APRN or PA ‘Signature of MD, D0, APRN or PA Date of Medical Examination — This physical expires 13 months from the date it was signed and dated by the MD, DO, APRN or PA.