Catholic Central High School “Cherishing the Past – Embracing the Future”

625 Seventh Avenue

Troy, New York 12182-2595

(518) 235-7100 – Fax 237-1796

www.cchstroy.org

Physical will be conducted on: Grade ___________

Date_______________

Time_______________

ATHLETIC HEALTH HISTORY

SCHOOL NAME: CATHOLIC CENTRAL HIGH SCHOOL

STUDENT: ____________________________________________________________ DOB: ______________________

Participation in athletics is voluntary and is not a required part of the regular physical education program.

SPORTS ACTIVITIES - Identify any sports in which you do not wish your child to participate:
___________________________________________________________________________________________________

___________________________________________________________________________________________________

THIS FORM MUST BE COMPLETED AND RETURNED ON THE DAY THE ATHLETE HAS HIS/HER PHYSICAL. THE APPOINTMENT DATE FOR THE PHYSICAL EXAMINATION IS IN THE UPPER LEFT HAND CORNER.

HEALTH HISTORY TO BE COMPLETED BY PARENT

Has your child ever had: (please check)

	YES	NO		YES	NO
Allergies/Hay Fever			Elevated Blood Pressure
Bee Sting Allergy			Headaches
Asthma			Head Injury/Concussion
Anemia			Heart Problem/Murmur-Chest Pain
Arthritis			Nose Bleeds/Frequent or Severe
Bladder/Kidney Problem or Injury			Ankle Injury
Convulsions/Seizures			Back Pain/Injury
Fainting Spells			Fracture-Dislocation Bones/Joints
Diabetes			Knee Pain/Injury
Ear Problems/ Hearing Loss			Neck Injury
Eye Problems/Vision Loss			Nose Fracture
Injury to the Spleen			Rheumatic Fever
Joint Sprain/Ligament Tear/Muscle Pull			Stomach Ulcer
				YES	NO
Is there a current medical examination on file in the nurse’s office?
Is your child assigned to the Adaptive Physical Education Program or has he/she been in the Adaptive Physical Education?
Has your child been unconscious or lost memory from a blow on the head?

History Continued

Does your child have any of the following:

	YES	NO
One eye or severe uncorrectable loss of vision in one or both eyes
Severe hearing loss in both ears
One kidney
One testicle
Has your child been ill for five (5) consecutive days? ________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________
Has your child ever had an illness, condition, or injury that required him/her to go to the hospital either as a patient overnight or in the emergency room or for x-rays; required an operation; caused your child to miss a game or practice? ______________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Is your child under medical care now?
Has your child taken any medication in the past year?o If so, why? __________________________________________________________________________ ____________________________________________________________________________________
Is your child taking any medications now? o If so, why? __________________________________________________________________________ ____________________________________________________________________________________
Has your child ever fainted during exercise If so, explain. ____________________________________________________________________________________
Has there ever been sudden death in a family member under fifty (50) years of age? ____________________________________________________________________________________
Do you have any worries about your child’s health or other questions you would like to discuss with a doctor?
Does your child have: orthodontic appliances?
Capped teeth?
Wear contact lenses for sports?
Wear glasses for sports?
Since your child’s last physical examination, has your child had any injury or illness? ____________________________________________________________________________________

I agree with the above answers and consent to participation of my child in the interscholastic program of his/her school including practice sessions and travel to and from the athletic contests.

I also agree to emergency medical treatment as deemed necessary by the physicians designed by school authorities.

PARENT/GUARDIAN

SIGNATURE:___________________________________________Date:_______________________________