Sports Questionnaire Update Form
Glens Falls City School District SPORTS CANDIDATES QUESTIONNAIRE
Sports Questionnaire Update
To be completed by parent or guardian if your child's physical is 30 days older than the season start date.
Athlete's Name *
Your answer
Grade *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Athletic Activity *
Anticipated Level *
History Since Last Medical Exam
Any medications to be taken at practice and/or athletic event will require the proper paperwork.
1. Since their last Physical have they been restricted by a doctor, PA or RNP from sports participation for any reason? *
2. Since last physical have they had any ongoing medical conditions? *
3. Since their last physical have they had any surgery? *
4. Since their last physical have they been diagnosed with Mononucleosis? *
5. Do they have only one functioning kidney? *
6. Do they have a bleeding disorder? *
7. Do they have any problems with their hearing or wear a hearing aid(s)? *
8. Have any problems with their vision or has vision in only one eye? *
9. Wear glasses or contacts? *
10. Have life threatening allergy? Check any that apply: *
11. Carry an epinephrine auto-injector? *
12. Ever complained of getting more tired or short of breath than their friends during exercise
13. Wheeze or cough frequently during or after exercise?
14. Ever been told by their health care provider they have asthma?
15. Use or carry an inhaler or nebulizer?
16. Ever had a hit to the head that caused headache, dizziness, nausea, confusion, or been told they had a concussion?
17. Have they ever had a head injury or concussion?
18. Ever had headaches with exercise?
19. Ever had any unexplained seizures?
20. Currently receiving treatment for a seizure disorder or epilepsy?
21. Use a brace, orthotic, or other device?
22. Have any special devices, or prostheses ( insulin pump, glucose sensor, ostomy bag, etc.)? If yes there may be need for another required form to be filled out.
23. Wear protective eye-wear, such as goggles or a face shield?
Family History
24 Have any relative who's been diagnosed with a heart condition, such as a murmur, developed hypertrophic cardiomyopathy, Marfan Syndrome, Brugada Syndrome, right ventricular cardiomyopathy, long QT or short QT syndrome, or catecholaminergic polymorphic ventricular tachycardia?
Females ONLY
25. Begun her period?
26. Age period began:
Your answer
27. Do you have regular periods?
Males ONLY
28. Have only one testicle?
29 Have groin pain or bulge or hernia in the groin?
Heart Health
30. Has your child ever passed out during or after exercise?
31. Has your child ever complained of light headedness or dizziness during or after exercise?
32. Has your child ever complained of chest pain, tightness or pressure during or after exercise?
33. Has your child ever complained of fluttering in their chest, skipped beats, or their heart racing or do they have a pacemaker?
34. Has your child ever had a test by their medical provider for their heart. (EKG, echocardiogram, stress test)?
35. Have they ever been told they have a heart condition or problem by a physician?
36. If you answered YES to question 35, check all that apply:
Injury History
37. Ever been diagnosed with a stress fracture?
38. Ever been unable to move their arms and legs, or had tingling, numbness, or weakness after being hit or falling?
39. Ever had an injury, pain, or swelling of joint that caused them to miss practice or a game?
40. Have a bone, muscle , or joint injury that bothers them?
41. Have joints that become painful, swollen, warm, or res with use?
Skin Health
42. Currently have any rashes, pressure sores, or other skin problems?
43. Have had herpes or MRSA skin infections?
Stomach Health
44. Ever become ill while exercising in hot weather?
45. Have a special diet or have to avoid certain foods?
46. Have to worry about their weight?
47. Have stomach problems?
48. Have they ever had an eating disorder?
Please explain fully any questions you answered YES to in the space below.
Your answer
Permission
We understand clearly that the questions are asked in order to decide if this student is in a proper condition to participate in the athletic activity named at the top of this form. The answers are correct as of the date this form is signed. All answers will be kept confidential in your child's health record in the school health's office.
Signature of Parent/Guardian *
By adding your name this is your verified electronic signature
Your answer
Signature of Parent/Guardian *
By adding your name this is your verified electronic signature
Your answer
Signature of student *
By adding your name this is your verified electronic signature
Your answer
Note: "Yes" answers to any of the questions above does not automatically disqualify the athlete from the activity indicated. This will require review and evaluation by the school physician.
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