NILES TOWNSHIP HIGH SCHOOL – North Division Sport(s) in which you plan to participate PLEASE LIST: i.e Football, Basketball, Baseball, Swimming, Tennis, Gymnastics, etc.
STUDENT ID # :__________________ Class (Circle One)
SOPH JR
SR
Fall________ Winter_______ Spring _______
PRESEASON MEDICAL HISTORY & PARTICIPATION EXAM FORM PART ONE: STUDENT INFORMATION To be completed by athlete or parent Name of student ________________________________________ Last First MI Gender:(Circle One) M F Address:________________________________________ City:__________________ Date of birth___________________ Are you a transfer student?_____yes ___no Name of previous school__________________________________ Past medical History Presently taking medication? Allergic to medicine, foods, bee stings? Wears any appliances, glasses, contacts? Has ongoing medical problem? Any past surgical operations, accidents or non-sports related injuries? Any past injuries directly related to sports? Any hospitalizations not explained above? Any known deformities (curvature of the spine, heart problems, kidney problems, blindness, one testicle, etc.)? Any serious family illness (diabetes, bleeding disorders, heart attack, or sudden death before the age of 50, etc.) Any fainting, wheezing or dizziness while exercising? Any loss of consciousness or head injury?
Yes ___ ___ ___ ___
No ___ ___ ___ ___
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PART TWO: PHYSICAL EXAMINATION To be completed by physician Height________ Weight_____ Blood Pressure________ Pulse: resting______ 15 hops_____ after 2 minutes____ Visual acuity: Eyes (R) 20/___ w/o glasses____(L)20/___ w/glasses Trunk Flexion____Scoliosis______Duck walk_______ Other Testing 1. General 2. Skin 3. Heent 4. Teeth 5. Neck 6. Lungs 7. Heart (Sit and Stand) 8. Abdomen 9. Genitalia 10. Musculoskeletal Neck Shoulder/Arm Elbow/Forearm Wrist/Hand Back Hip/Thigh Knees Skin/Calf Ankle/leg Foot 11. Peripheral Pulses
Normal ______ ______ ______ ______ ______ ______ ______ ______ ______
Abnormal Findings ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________
______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________
Part Two: Physician Examination (Continued) 12. Neurologic 13. Mental Status 14. Marfan Screen
______ ______ ______
Other Tests (optional) ____Auditory ____U/A ____% Body Fat ____Drug Screen ____Hgb/Het ____SMAC
______________________ ______________________ ______________________
_____EKG _____Chest X-Ray _____Marfan screen
Part Three: Student Participation and Parental Approval This application to compete in interscholastic athletics for Niles North High School is entirely voluntary on may part and is made with the understanding that I have not violated any of the eligibility rules and regulations of Niles North, the CSL and the Illinois High School Association. Signature of Student_____________________________________ Parent or Guardian's Permission
Assessment: 1. Clearance without limitations
Sports____________________ ____________________ ____________________ 2. Clearance deferred Reason:_______________________ _______________________ _______________________ 3. Clearance with limitation Limitation:____________________ _______________________ ________________________ 4. Disqualification Reason________________________ ________________________ ________________________ Additional comments:____________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ I certify that I have on this dated examined this student that, on the basis of the examination requested by the school authorities and the student's medical history as furnished to me, the student may compete in the above athletic activities. Physician's Signature____________________________________ Physician's Stamp______________________________________
Date of Examination: _____________ Physician's Telephone:____________________
I hereby give my consent for the above named student to (1)
(2)
Represent his/her school in athletic activities approved on this form by examining physical provided that such athletic activities are approved by Niles North, and accompany any school team of which he/she is a member on any of its local or out-of-town trips.
I authorize the school to obtain, through a physician of its own choice, any emergency medical care that may be reasonable necessary for the student in the course of such athletic activities or such travel. I also agree not to hold the school or anyone acting on its behalf responsible for any injury occurring to the above named student in the course of such athletic activities or such travel. My son/daughter is adequately covered by personal or group insurance. Signature of parent or guardian_______________________________ Date:____________________ PLEASE BE SURE THAT BOTH SIDES OF THIS FORM HAVE BEEN COMPLETED
