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Sports Screening
To be completed by parent/legal guardian
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Hamilton Perez *
Birthdate Month/Day/Year *
Sport *
Sport Level *
Grade *
Physical Date *
Screening questions *
Have you ever passed out during or after exercise?
Have you ever had chest pain during or after exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you ever been told you have a heart murmur?
Has any family member or relative died of heart problems or of sudden death before the age of 50?
Have you had a severe viral infection (e.g. myocarditis or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in sports for any heart problem?
Please explain any "Yes" answers: *
A: The student as named above has my permission to receive a physical screening by the designated school health care provider, unless one is provided by the student's own health care provider and a copy is supplied to the school. B: The student has my permission to engage in all prescribed activities except as noted by me, the student’s private health provider, or the schools designated health care provider. C: The student’s parent or guardian is responsible for notifying the team coach and school nurse should an injury or serious illness occur within the year in which the form is valid. D: In the event I cannot be reached in an emergency, I hereby give my permission for the coach/nurse/teacher to contact Emergency Medical Services and the student to be transported to the nearest Emergency Room as deemed urgently medically necessary. I have read and fully understand statements A, B, C & D. I understand that if I wish my students private provider to do the physical screening, I must have that provider complete a Sports Screening Form as well as the NYS School Health Examination Form in their entirety and return the forms to the school nurse. I have answered all questions to the best of my ability. Please type parent/guardian name below: *
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